Tinkering supervision, patient safety and quality of care in general practice and elderly care medicine residency training

Quality and safety in patient care can only be provided if doctors are well prepared during medical training, for which active participation in meaningful activities is paramount. Supervision needs to vary according to the trainee’s experience, allowing for progressive independence. However, in most medical errors in hospitals, trainee doctors are involved. Research about patient safety and supervision in out-of-hospital settings is limited. Complexity and uncertainty in general practice and the nursing home will increase while residents entering postgraduate training are younger and less experienced than they were a decade ago. Currently, there is a lack of evidence clarifying how adequate supervision in relation to patient safety should be enacted. The main purpose of this research project is to improve supervision in the specific learning environments of the nursing home and general practice. First, we aim to gain more insight into how patient safety can be balanced with the developmental needs of physicians in training. Secondly, we will describe how salient factors in the learning environment, such as attitudes towards uncertainty, complexity and patient safety, interprofessional collaboration, communication and the disclosure of errors, influence patient safety and learning opportunities in elderly care medicine and general practice. We will address supervisors’ uncertainties about when to entrust activities to learners and how to decide which level of supervision is needed and we aim to unravel the uncertainties and difficulties for trainees as they choose whether or not to ask for supervision. As a result, we aim to develop an educational model for supervision, which can help trainers and trainees to define current stages of autonomy and responsibility, recognise and respect boundaries of safe practice and adequately balance quality of care and developmental space. Ultimately, this may lead to practical recommendations for the development of a teaching module or topic guide informing both residents and supervisors in general practice and elderly care medicine. We will address the following research questions: 1) What are the characteristics of current supervision practices in elderly care medicine and general practice particularly in the context of complexity and uncertainty?; 2) How can we balance patient safety with graded autonomy and responsibility of trainees in elderly care medicine and general practice?; 3) How can the answers to the former questions be translated in practical recommendations for graded supervision? We propose to carry out a mixed-methods qualitative study, with constructivist grounded theory as a main methodology. We will include trainees and supervisors in both general practice and elderly care medicine in four consecutive studies. Study 1 is an individual interview study directed at how trainees and supervisors respond to uncertainty and complexity in patient care and supervision. Study 2 will consist of focus group interviews with trainees and supervisors in elderly care medicine and general practice directed at how supervision is currently enacted. Study 3 will be an observational study including observations and supplementary interviews at the workplace in both contexts encompassing formal supervision moments, patient encounters, and interprofessional team meetings, both during daily practice and on-call / out-of-hours. Study 4 is a Delphi study to develop practical recommendations for graded supervision based on the previous studies and input from experts. As one of the main outcomes of this research project will be a set of practical recommendations for graded supervision, serving as a basis for the development of a teaching module or topic guide about supervision and patient safety during medical training for both residents and supervisors in general practice and elderly care medicine, implementation of our educational model and the practical recommendations into GP and elderly care medicine specialty training programs in the Netherlands will be the main goal for knowledge utilisation. Therefore, our most important stakeholders are postgraduate training boards, programme directors, educationalists, trainees and supervisors of the GP specialty training programmes and elderly care medicine specialty training programmes in the Netherlands. Throughout the project, we will discuss the findings with the programme directors of the specialty training programmes of both the Academic Medical Center and the VUmc to allow findings to inform current curriculum changes. We will present and discuss our finding at the interdepartmental meetings (‘interstaven dagen’) of both specialty training programmes, in the specialisation course for supervision (Kaderopleiding voor Opleiders) offered by the central board for elderly care medicine speciality training (SOON) and at (inter)national conferences on medical education.