Remediating doctors’ performance to restore patient safety: a realist review protocol

Price, Tristan; Brennan, Nicola; Cleland, Jennifer; Prescott‐Clements, Linda; Wanner, Amanda; Withers, Lyndsey; Wong, Geoff; Archer, Julian

doi:10.1136/bmjopen-2018-025943

Cited by 12 publications

(14 citation statements)

References 29 publications

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“…There is a need for research that provides a firm theoretical base to help design effective interventions to remediate professionalism lapses in doctors in different contexts . NB, TP and JA are currently leading a study funded by the National Institute for Health Research to explore this issue …”

Section: Discussionmentioning

confidence: 99%

“…Remediation can be defined as an intervention or a range of interventions ‘required in response to assessment against a threshold standard of performance.’ Remediation interventions vary from informal agreements to undertake some reskilling to more formal programmes of remediation and rehabilitation, with most based around a three‐step model that involves the identification of a performance deficit, the implementation of a remediation intervention and retesting after the intervention . Given that doctors are both expensive to train and in short supply, remediating a doctor who is underperforming and returning that individual to safe practice may be both more practical and financially viable than removing the doctor from practice altogether …”

Section: Introductionmentioning

confidence: 99%

“…9 Given that doctors are both expensive to train and in short supply, remediating a doctor who is underperforming and returning that individual to safe practice may be both more practical and financially viable than removing the doctor from practice altogether. 10,11 Remediation has been classified as a 'wicked' problem with which the medical profession has struggled for decades. 12 One of the reasons for this refers to the fact that remediation has tended to be conceptualised as an educational issue; however, few studies are underpinned by educational theory.…”

Section: Introductionmentioning

confidence: 99%

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Remediating professionalism lapses in medical students and doctors: A systematic review

et al. 2019

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Context A remediation intervention aims to facilitate the improvement of an individual whose competence in a particular skill has dropped below the level expected. Little is known regarding the effectiveness of remediation, especially in the area of professionalism. This review sought to identify and assess the effectiveness of interventions to remediate professionalism lapses in medical students and doctors. Methods Databases Embase, MEDLINE, Education Resources Information Center and the British Education Index were searched in September 2017 and October 2018. Studies reporting interventions to remediate professionalism lapses in medical students and doctors were included. A standardised data extraction form incorporating a previously described behaviour change technique taxonomy was utilised. A narrative synthesis approach was adopted. Quality was assessed using the Critical Appraisal Skills Programme checklist. Results A total of 19 studies on remediation interventions reported in 23 articles were identified. Of these, 13 were case studies, five were cohort studies and one was a qualitative study; 37% targeted doctors, 26% medical students, 16% residents and 21% involved mixed populations. Most interventions were multifaceted and addressed professionalism issues concomitantly with clinical skills, but some focused on specific areas (eg sexual boundaries and disruptive behaviours). Most used three or more behaviour change techniques. The included studies were predominantly of low quality as 13 of the 19 were case studies. It was difficult to assess the effectiveness of the interventions as the majority of studies did not carry out any evaluation. Conclusions The review identifies a paucity of evidence to guide best practice in the remediation of professionalism lapses in medical students and doctors. The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can facilitate participants to graduate from a programme of study, and pass medical licensing and mock oral board examinations. However, it is not clear from this literature whether these interventions are successful in remediating lapses in professionalism specifically. Further research is required to improve the design and evaluation of interventions to remediate professionalism lapses.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Remediating professionalism lapses in medical students and doctors: A systematic review

et al. 2019

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“…The review was registered with PROSPERO (CRD42018088779) and the protocol was published in BMJ Open. 34 The review was informed by the quality and publication standards and training materials for realist reviews that were developed by one of the core research team members (GW). 35 We were granted ethics clearance by the University of Plymouth, Faculty of Health and Human Sciences and Faculty of Medicine and Dentistry Research Ethics and Integrity Committee.…”

Section: Review Questionsmentioning

confidence: 99%

Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review

Price

Brennan

Wong

et al. 2021

Health Serv Deliv Res

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Background An underperforming doctor puts patient safety at risk. Remediation is an intervention intended to address underperformance and return a doctor to safe practice. Used in health-care systems all over the world, it has clear implications for both patient safety and doctor retention in the workforce. However, there is limited evidence underpinning remediation programmes, particularly a lack of knowledge as to why and how a remedial intervention may work to change a doctor’s practice. Objectives To (1) conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety; and (2) provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors. Design A realist review of the literature underpinned by the Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards. Data sources Searches of bibliographic databases were conducted in June 2018 using the following databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center, Database of Abstracts of Reviews of Effects, Applied Social Sciences Index and Abstracts, and Health Management Information Consortium. Grey literature searches were conducted in June 2019 using the following: Google Scholar (Google Inc., Mountain View, CA, USA), OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. Further relevant studies were identified via backward citation searching, searching the libraries of the core research team and through a stakeholder group. Review methods Realist review is a theory-orientated and explanatory approach to the synthesis of evidence that seeks to develop programme theories about how an intervention produces its effects. We developed a programme theory of remediation by convening a stakeholder group and undertaking a systematic search of the literature. We included all studies in the English language on the remediation of practising doctors, all study designs, all health-care settings and all outcome measures. We extracted relevant sections of text relating to the programme theory. Extracted data were then synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations. Results A total of 141 records were included. Of the 141 studies included in the review, 64% related to North America and 14% were from the UK. The majority of studies (72%) were published between 2008 and 2018. A total of 33% of articles were commentaries, 30% were research papers, 25% were case studies and 12% were other types of articles. Among the research papers, 64% were quantitative, 19% were literature reviews, 14% were qualitative and 3% were mixed methods. A total of 40% of the articles were about junior doctors/residents, 31% were about practicing physicians, 17% were about a mixture of both (with some including medical students) and 12% were not applicable. A total of 40% of studies focused on remediating all areas of clinical practice, including medical knowledge, clinical skills and professionalism. A total of 27% of studies focused on professionalism only, 19% focused on knowledge and/or clinical skills and 14% did not specify. A total of 32% of studies described a remediation intervention, 16% outlined strategies for designing remediation programmes, 11% outlined remediation models and 41% were not applicable. Twenty-nine context–mechanism–outcome configurations were identified. Remediation programmes work when they develop doctors’ insight and motivation, and reinforce behaviour change. Strategies such as providing safe spaces, using advocacy to develop trust in the remediation process and carefully framing feedback create contexts in which psychological safety and professional dissonance lead to the development of insight. Involving the remediating doctor in remediation planning can provide a perceived sense of control in the process and this, alongside correcting causal attribution, goal-setting, destigmatising remediation and clarity of consequences, helps motivate doctors to change. Sustained change may be facilitated by practising new behaviours and skills and through guided reflection. Limitations Limitations were the low quality of included literature and limited number of UK-based studies. Future work Future work should use the recommendations to optimise the delivery of existing remediation programmes for doctors in the NHS. Study registration This study is registered as PROSPERO CRD42018088779. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

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“…With guidance of surgical educators, it is expected that surgical trainees incrementally develop skills during their training across established core competencies 1 . Occasionally, some trainees show considerable and/or repeated underperformance which requires remediation, defined ‘as one or more interventions in response to assessment against a threshold standard of performance’ 2 . Remediation is complex as the underperformance itself is usually multifactorial, related to the trainee's workplace and social and personal responsibilities that influence their learning capacity 3 .…”

Section: Introductionmentioning

confidence: 99%

Remediation for surgical trainees: recommendations from a narrative review

Cargill

Tobin

et al. 2021

ANZ Journal of Surgery

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Remediation involves formalized support for surgical trainees with significant underperformance to return to expected standards. We have reviewed current published literature to understand the evidence for remediation of surgical trainees to inform practice and justify investment of resources. If performed in a programmatic framework, it is a complex but often successful approach to return surgical trainees to their expected standard using system and process level changes.

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Remediating doctors’ performance to restore patient safety: a realist review protocol

Cited by 12 publications

References 29 publications

Remediating professionalism lapses in medical students and doctors: A systematic review

Remediating professionalism lapses in medical students and doctors: A systematic review

Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review

Remediation for surgical trainees: recommendations from a narrative review

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