背景:关于临床表现的反馈旨在为医疗机构中的团队提供有关其表现的结构化结果,以改善这些结果。包括147项随机研究的两项系统评价显示,在专业人员对所需临床实践的依从性方面存在未解决的差异。改善临床团队绩效反馈的传统建议通常显得去文化化,并且,在这方面,理想化。反馈涉及人类和非人类实体以及相互关系的复杂多样的安排。为了探索这种复杂性并改进反馈,我们试图解释对临床团队绩效的反馈是如何工作的,为谁,在什么情况下,以及有什么变化。我们在这项研究中的目标是为医疗保健环境中的临床团队提供对反馈及其结果的现实和情境化解释。
方法:这项批判性的现实主义者定性多案例研究包括3例异质性病例和98名来自一所大学附属三级护理医院的专业人员。使用了五种数据收集方法:参与者观察,文档检索,焦点小组,半结构化面试,和问卷调查。在数据收集过程中进行的案例内和案例间分析涉及主题分析,分析性提问,和系统建模。这些方法得到了研究团队之间关键的反身对话的支持,合作者,和一个专家小组。
结果:尽管整个机构都使用了单一的实施模型,结果在上下文决策结构上有所不同,对争议的回应,反馈循环实践,以及使用各种技术或混合中介。结构和行动保持或改变相互关系,并产生符合预期或原始解决方案出现的变化。变化与机构和地方项目或指标结果的实施有关。然而,它们不一定反映临床实践或患者结局的变化.
结论:这个批判性的现实主义者定性多案例研究提供了对临床团队绩效的反馈的深入解释,该团队是一个复杂的开放式社会技术系统,在不断转型中。在这样做的时候,它确定了反身性问题,这些问题是改善团队反馈的杠杆。
BACKGROUND: Feedback on clinical performance aims to provide teams in health care settings with structured results about their performance in order to improve these results. Two systematic reviews that included 147 randomized studies showed unresolved variability in professional compliance with desired clinical practices. Conventional recommendations for improving feedback on clinical team performance generally appear decontextualized and, in this regard, idealized. Feedback involves a complex and varied arrangement of human and non-human entities and interrelationships. To explore this complexity and improve feedback, we sought to explain how feedback on clinical team performance works, for whom, in what contexts, and for what changes. Our goal in this research was to present a realistic and contextualized explanation of feedback and its outcomes for clinical teams in health care settings.
METHODS: This critical realist qualitative multiple
case study included three heterogeneous cases and 98 professionals from a university-affiliated tertiary care hospital. Five data collection methods were used: participant observation, document retrieval, focus groups, semi-structured interviews, and questionnaires. Intra- and inter-
case analysis performed during data collection involved thematic analysis, analytical questioning, and systemic modeling. These approaches were supported by critical reflexive dialogue among the research team, collaborators, and an expert panel.
RESULTS: Despite the use of a single implementation model throughout the institution, results differed on contextual decision-making structures, responses to controversy, feedback loop practices, and use of varied technical or hybrid intermediaries. Structures and actions maintain or transform interrelationships and generate changes that are in line with expectations or the emergence of original solutions. Changes are related to the implementation of institutional and local projects or indicator results. However, they do not necessarily reflect a change in clinical practice or patient outcomes.
CONCLUSIONS: This critical realist qualitative multiple
case study offers an in-depth explanation of feedback on clinical team performance as a complex and open-ended sociotechnical system in constant transformation. In doing so, it identifies reflexive questions that are levers for the improvement of team feedback.