This realist review has developed a programme theory of how remediation works to produce outcomes that ensure patient safety. The key academic contributions of this review are listed below.
- Remediation is most usefully conceptualised in terms of practice change because of the uniqueness of the environment in which remediation occurs and the subsequent nature of the barriers that arise in engaging doctors in successful remediation.
- For remediation to be successful, remediating doctors must develop insight. Insight entails both a readiness to engage with and validate others’ perceptions of one’s own performance, and acceptance of the need for change. Insight can be developed when supportive and confidential environments are created, when advocacy can be used to enhance levels of emotional support and when feedback is carefully framed so that it creates dissonance leading to change, rather than denial or rejection (CMOcs 1–13).
- Doctors must be motivated to engage with remediation. This is often challenging because being identified as needing remediation can be demotivating. Engaging doctors with remediation planning can foster motivation by mitigating the loss of autonomy that is inherent in undergoing remediation for practising doctors, and by enhancing perceptions of control. Similarly, setting realistic and incremental goals will help (CMOcs 14–23).
- Remediation plans are effective when they afford the opportunities for remediating doctors to practise behaviours and skills in a simulated environment. Importantly, in terms of behaviour, understanding that behaviours are wrong may not be enough, and practising new behaviours may facilitate behavioural change (CMOcs 24 and 25).
- Processes of reflection are central to facilitating remediation. However, despite the centrality of reflection to the process, assessing reflection itself may undermine its transformative potential. Written reflections on a remediation process may help give meaning to feedback received. Guided reflection with a skilled coach is an effective way of giving meaning to feedback and helping ensure that feedback helps to develop insight (CMOcs 26–29).
- It is important to evaluate any organisational issues that may contribute to poor performance or behaviour. This will help determine whether or not the work environment is a contributory factor, and whether or not this environment will be suitable for undertaking remediation activities.
There are a number of significant implications related to the findings from our review. First, focusing remediation interventions on developing insight will be an important first step for a remediation programme. Insight is a necessary condition for successful remediation. Bringing about insightful practice may require remediation programmes to give significant attention to the way in which feedback is framed and the environments created for reflective practice. This is important because practising doctors are often not functioning within an educational environment in which making mistakes and learning from those mistakes is an integral part of the process. Rather, doctors function in an environment (more or less, depending on their stage of training and/or their role) in which a return to a more educational environment entails a loss of autonomy and is likely to invoke adverse reaction. This brings into focus a careful consideration of how the roles in remediation are structured, and how the remediation programme can create facilitative environments for feedback to be accepted.
If the important processes that function within a remediation programme relate to behavioural change, then it is important to acknowledge that the transformative learning that really matters may be some of the most difficult to measure. Intermediate outcomes essential to the remediation process, related to insight and motivation, may be assessed through the qualitative judgements of trained individuals who are able to identify, respond, frame feedback, challenge (in a supportive way) and recognise when reflection is a genuine rather than strategic endeavour. If programmes focus on only measurable outcomes, they may not be able to deliver sustainable practice change.
This in turn points to issues of resource allocation. We have not sought here to prescribe the exact structure of a remediation team. Our recommendations are designed to work with existing programmes and are subsequently broad in their scope. However, our findings do suggest that the training of individuals in coaching- and mentoring-type roles should be a priority for remediation programmes, rather than an optional extra.
RESTORE review recommendations
Based on our findings, we have developed a series of recommendations for those working to deliver remediation programmes, on tailoring, implementation and design strategies to improve remediation interventions for doctors (Table 14). Although this review did not include studies on other health-care professionals, these recommendations would also be relevant for other health-care professionals.
| Finding | Recommendation |
|---|---|
| 1. Remediation programmes work when they develop insight | |
| 1.1 Safe spaces for confidential discussion help a remediating doctor become ready to explore issues related to their performance or behaviour | Remediating doctors should have the opportunity for confidential discussion with someone in a supportive role |
| 1.2 Juxtaposing a remediating doctor’s own values with their actual behaviours help remediating doctors accept the need for change | Remediation programmes for issues related to conduct should include an opportunity for remediating doctors to reflect on their own professional values and contrast these with the feedback they receive on their own behaviours |
| 1.3 When a remediating doctor has the support of an advocate who has no role in summative judgements then they are more likely to develop trust in the remediation process | Remediating doctors should be supported by someone who has the role of advocate. This individual may be a coach or mentor, and should not have a role in making summative judgements throughout the remediation programme |
| 1.4 When feedback on performance/behaviour is specific and comes from multiple sources it is more likely to be validated by a remediating doctor | Remediating doctors should be provided with specific feedback that details the reasons and provides examples of underperformance or poor conduct. If the feedback relates to behaviour, it should detail specific events with a date and time This feedback should ideally come from more than one source and include feedback from patients whenever possible Feedback will be needed throughout the remediation process, not just at the beginning. The appropriate feedback to determine progress, and the way that it is delivered, should be ascertained in the remediation planning stage |
| 1.5 When feedback is framed in a way that is sensitive to a doctor’s professional identity, they are less likely to reject that feedback and may accept the need to change performance or behaviour to align with their own professional values | Feedback may be more effective when in person and should be guided by someone who has been trained to deliver feedback. The feedback should be framed in such a way that it relates to the professional values of the doctor, is presented in a way that seems manageable and affirms any identified strengths |
| 1.6 Remediation is more likely to be successful when assessment is used to explore and identify the full range of possible causes for a ‘problem’ | Multimodal assessment should be used to explore a full range of potential issues, including behavioural issues, even when the identified problem may appear to relate to knowledge and skills Assessment should also be used to determine any organisational issues that may contribute to poor performance or behaviour. This will help determine whether or not the work environment is a contributory factor, and whether or not this environment will be suitable for undertaking remediation activities. If there are problems with the work environment, then remediation may need to be conducted elsewhere |
| 1.7 When remediating doctors are facilitated to identify and reflect on the triggers of poor performance or unprofessional behaviour, they may be able to avoid these reactions in the future | Remediation programmes should offer the opportunity for the remediating doctor to reflect on the reasons for their referral and to identify the triggers for underperformance/poor conduct |
| 2. Remediation programmes work when they motivate practitioners to change | |
| 2.1 If a remediating doctor has input into the design of an individualised remediation programme then they are more likely to have buy-in to the programme and will be more motivated to engage | When possible, remediating doctors should collaborate in the design of the individualised remediation plan and help to shape it. The planning stage should include setting scheduled points for assessing progress and determining what kind of feedback will be appropriate for the assessment of this progress |
| 2.2 When part of the remediation planning process includes setting realistic and achievable goals, the remediating doctor may feel that they are more capable of achieving these goals | The remediating doctor should collaborate in the process of goal-setting, and the goals set should be achievable and measurable |
| 2.3 When remediating doctors are clear about what happens when targets are achieved or not achieved then they are more likely to choose to engage in the remediation programme | Remediation programmes should include an individualised plan that specifies the milestones, points for review of progress and the consequences of achieving or not achieving targets |
| 2.4 If efforts are made to destigmatise remediation, wherever possible, remediating doctors are more likely to engage with the process and be more motivated because there is less of a threat to their professional identity | Remediation programmes should seek to destigmatise the process of undergoing remediation and frame it, as far as possible, in terms of positive professional development If relevant, remediation programmes could consider changing the name from remediation to professional support or similar. Positive framing may also include changing the language around the guidance for remediation to include terms that indicate support and development |
| 3. Remediation programmes work when changes to practice are facilitated | |
| 3.1 When there is an opportunity for remediating doctors to practise new performance or behaviours then these new performances or behaviours are more likely to be integrated into their practice | When appropriate, remediation programmes should offer an opportunity for remediating doctors to practise any new skills or behaviours they have developed. This may include rehearsing new behaviours in simulated settings. When this is not possible, guided reflection can offer an opportunity to reflect on in situ practice |
| 3.2 When there are scheduled points for guided reflection, remediating doctors have more opportunity to integrate new knowledge and skills and develop further insight | Remediation programmes should have scheduled points for reviewing progress with the remediating doctor. The remediating doctor should be involved in this process of review and reflections should be guided so that the remediating doctor continues to gain insight into their progress |
| 3.3 When the remediating doctor has an active role in reflecting on feedback then the feedback is more likely to be accepted and engender a change in performance | Reflection should be built into the remediation programme and should be guided, but not form part of a final judgement on progress. Reflection may include one-to-one discussion of feedback or discussions of entries in reflective logs. The purpose of reflection is to have an interesting and meaningful conversation to embed new knowledge and behaviours and engender further insight Recent medico legal cases may have placed uncertainty over the confidentiality of reflective logs. The exact legal status of any written reflections should be established in advance |
Strengths and limitations
The main strengths of this report are the way that we have carried out a robust and thorough realist analysis, following Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality standards for realist synthesis.35 This has allowed us to go beyond the explanations provided in the existing data to build theories about how remediation works in different circumstances. Although previous reviews have focused on outcomes related to only quantifiable measures, such as pass/fail tests scores or programme completion/attrition, we have been able to uncover a range of intermediate outcome measures that form important points in a remediation journey. This has allowed us to uncover what is working (or not) in remediation programmes.
We have had excellent input from a diverse range of stakeholders with various expertise in remediating doctors, as well as PPI input to ensure that a patient voice has been present in all discussions. The stakeholders have been central throughout all stages of the process, including sense-checking our findings against their real-world experience and directly contributing to aspects of the theory-building process. This has enabled us to develop findings that are relevant at the level of policy and practice. As realist reviewing develops theory at a level of abstraction that is transferable and above the level of the intervention itself, a further strength of the realist approach is that the findings do not provide just a single model of how a remediation programme should be structured; rather, our findings offer guidance for implementing strategies that work in certain contexts and that could be applied to a range of remedial intervention types. This enhances the versatility of our findings, maximising their relevance to the broad range of remediation programmes that exist across the NHS.
The main weakness of this review is that, as with any review of existing evidence, it is limited by the quality of the literature reviewed. In this case, the literature was generally of a low quality in terms of a lack of robust studies. Much of the more theoretically rich data for developing the programme theory were derived from reports of existing programmes, rather than studies or evaluations of programmes. The studies that we did find that were more robust were generally not theoretically rich (i.e. they did not tell us much about how the programme worked to produce its effects). To some extent, the iterative, theory-building approach used in realist reviews allowed us to transcend these limitations, as theories could be built and tested against the different types of relevant data drawn from across studies and related topic areas, as well as having a critical input from our stakeholder group. We also have to acknowledge that only a small proportion of the literature we reviewed came from the UK. Most of the literature was from North America and therefore the programmes covered in the literature were not always directly transferable to the UK context. Again, our stakeholder group was indispensable in helping to ensure that the findings made sense in the UK context. We managed to recruit only one doctor who had undergone remediation to the stakeholder group (albeit one of the stakeholders had undergone remediation during medical school). Having more doctors in the stakeholder group who had undergone remediation may have provided more of a variety of perspectives on the experience of undergoing remediation and how remediation produces its effect. As mentioned in the methods section in Chapter 2, we tried different ways to recruit more remediating doctors to the stakeholder group. For future research, contacting professional support units outside the south-west of the UK may be more fruitful.
A final potential weakness, relating to the realist review methodology, is that these findings are a result of our interpretation of the data. We accept that other researchers could interpret the data differently. However, we strongly believe that our explanations of the data are plausible and have been thoroughly tested through a robust, iterative process.
Future research
We propose three areas for future research.
- Future research can build on the work presented here to evaluate and refine remediation interventional strategies that have been already implemented, or design, implement and evaluate new interventional strategies.
- Although we have successfully identified why remediation programmes work in some contexts and not others, we also recognise that a greater understanding of the specific contexts relevant to real-world NHS settings is required. A high proportion of studies included in our review emanate from North America (64%), where the organisation of both health-care and remediation programmes is very different from the UK. Therefore, there is a need for better specification of our programme theory to NHS settings. Future research should focus on using our evidence-based recommendations to optimise the delivery of remediation programmes for doctors in the NHS and then evaluating these changes using a realist evaluation approach. This would result in an improvement of existing programmes in the NHS and would also enable us to further test, refine, confirm or refute our programme theory of remediation and to identify other potential mechanisms at work in the remediation process, as well as other important contexts specific to the NHS.
- Another avenue for future research involves investigating the topic of remediation relating to other health-care professions, which lag behind medicine in terms of support structures for underperforming individuals. This could involve an extended realist review looking at literature from other health-care professionals.