Une étude clinique de l'activité de médecin de premier secours : vers une modélisation d'une profession complexe

Ce travail a pour objectif d'étudier l'évolution du métier de médecin de premier recours à la lumière du réel de son activité. Afin de pallier les lacunes de la littérature, nous proposons d'investiguer les perceptions et les pratiques rapportées de médecins de premier recours, considérant leur activité comme située dans un contexte spécifique. Un cadre théorique multiréférencé, intégrant les apports de Bischoff (2012), de la théorie de l'activité (Engeström et al., 1999), de l'ergonomie (Daniellou, 1996 ; Falzon, 2004a; Leplat, 1997) et de certains courants de la psychologie du travail (Curie et al., 1990 ; Curie, 2000b ; Malrieu, 1989) permet de tenir compte de la complexité du travail des médecins de premier recours. Une méthodologie mixte, alliant une approche qualitative par entretiens semi-structurés (n=20) à une approche quantitative par questionnaire (n=553), a été développée. Les résultats de l'analyse thématique des entretiens mettent en évidence trois thèmes majeurs : l'Evolution du métier (Thème 1), caractérisé par les changements perçus, les demandes des populations qui consultent et les paradoxes et vécus des médecins ; les Ajustements et supports (Thème 2) mis en place par les médecins pour faire face aux changements et aux difficultés de leur métier ; les Perceptions et les attentes par rapport au métier (Thème 3), mettant en avant des écarts perçus entre la formation et la réalité du métier. La partie quantitative permet de répondre aux questionnements générés à partir des résultats qualitatifs et de généraliser certains d'entre eux. Suite à l'intégration des deux volets de l'étude, nous présentons une nouvelle modélisation du métier de médecin de premier recours, soulignant son aspect dynamique et évolutif. Cette modélisation rend possible l'analyse de l'activité réelle des médecins, en tenant compte des contraintes organisationnelles, des paradoxes inhérents au métier et du vécu des médecins de premier recours. L'analyse des limites de cette étude ouvre à de nouvelles perspectives de recherche. A l'issue de ce travail, nous proposons quelques usages pragmatiques, qui pourront être utiles aux médecins de premier recours et aux médecins en formation, non seulement dans la réalisation de leur activité, mais également pour le maintien de leur équilibre et leur épanouissement au sein du métier. - This study aims to investigate the evolution of primary care physicians' work, in the light of the reality of their activity. In order to overcome the limitations of the literature, we propose to focus on primary care physicians' reported perceptions and practices, considering their activity as situated in a specific context. The theoretical framework refers to Bischoff (2012), Activity theory (Engeström et al., 1999), ergonomy (Daniellou, 1996; Falzon, 2004a; Leplat, 1997) and work psychology (Curie et al., 1990 ; Curie, 2000b ; Malrieu, 1989) and enables to take into account the complexity of primary care physicians' work. This mixed methods study proposes semi-structured interviews (n=20) and a questionnaire (n=553). Thematic analysis of interviews points out three major themes : Evolution of work (Theme 1) is characterised by perceived changes, patients' expectations and paradoxes ; Adjustments and supports (Theme 2), that help to face changes and difficulties of work ; Perceptions related to work, including differences between work reality as represented during medical education/training and actual work reality. Quantitative part of the study enables to answer questions generated from qualitative results and to generalise some of them. Integration of qualitative and quantitative results leads to a new modelling of primary care physicians ' work, that is dynamic and evolutionary. This modelling is useful to analyse the primary care physicians' activity, including organisational constraints, paradoxes of work and how primary care physicians are experiencing them. Despite its limitations, this study offers new research perspectives. To conclude, we state pragmatic recommendations that could be helpful to primary care physicians in private practice and junior doctors, in order to realise their activity, to maintain their balance and to sustain their professional fulfilment.

Expert clinical reasoning and pain assessment in mechanically ventilated patients: A descriptive study.

BACKGROUND: Pain assessment in mechanically ventilated patients is challenging, because nurses need to decode pain behaviour, interpret pain scores, and make appropriate decisions. This clinical reasoning process is inherent to advanced nursing practice, but is poorly understood. A better understanding of this process could contribute to improved pain assessment and management. OBJECTIVE: This study aimed to describe the indicators that influence expert nurses' clinical reasoning when assessing pain in critically ill nonverbal patients. METHODS: This descriptive observational study was conducted in the adult intensive care unit (ICU) of a tertiary referral hospital in Western Switzerland. A purposive sample of expert nurses, caring for nonverbal ventilated patients who received sedation and analgesia, were invited to participate in the study. Data were collected in "real life" using recorded think-aloud combined with direct non-participant observation and brief interviews. Data were analysed using deductive and inductive content analyses using a theoretical framework related to clinical reasoning and pain. RESULTS: Seven expert nurses with an average of 7.85 (±3.1) years of critical care experience participated in the study. The patients had respiratory distress (n=2), cardiac arrest (n=2), sub-arachnoid bleeding (n=1), and multi-trauma (n=2). A total of 1344 quotes in five categories were identified. Patients' physiological stability was the principal indicator for making decision in relation to pain management. Results also showed that it is a permanent challenge for nurses to discriminate situations requiring sedation from situations requiring analgesia. Expert nurses mainly used working knowledge and patterns to anticipate and prevent pain. CONCLUSIONS: Patient's clinical condition is important for making decision about pain in critically ill nonverbal patients. The concept of pain cannot be assessed in isolation and its assessment should take the patient's clinical stability and sedation into account. Further research is warranted to confirm these results.