Abstract
Learning in the workplace is the basis of postgraduate medical education and training. Essentially, you learn to be a doctor by being one. Each training programme has formal educational activities. Doctors in training must undertake independent study, but the most important element of training is the opportunity to undertake medical practice, under appropriate supervision. Although supervision has such a vital role in medical education, it is probably the least investigated and least developed aspect of clinical teaching. This article reviews current understanding and requirements about supervision and concludes that these suggest new directions for developing supervisory practices.
The GP curriculum and supervision
GP
Understand the nature and purpose of mentoring and of clinical and educational supervision Identify the different forms that mentoring and clinical supervision (formal and informal) can take and also the benefits and limitations of these
Supervision, not mentoring, is the focus of this article. There are specific requirements about supervision, but not mentoring, in specialist training. This article will begin by outlining current requirements about supervision in postgraduate medical education and training. In order to illustrate the nature and purpose of supervision, and the different forms it can take, I will briefly summarize some relevant research about supervision. The benefits and limitations of different forms of supervision are more apparent if the complexities of supervision activities and relationships are understood. I will conclude by arguing that supervision cannot be separated from clinical activity and that this understanding can contribute towards more effective supervision and learning in clinical settings. This article is relevant for both supervisors and GP registrars (who, of course, often supervise other, more junior doctors at the same time as they are being supervised) — a better understanding of the complexities of supervision will assist everyone to develop more effective supervision practices.
Supervision in postgraduate medical education
Supervision is a required part of both the Foundation Programme and the speciality training. Although in the past there was a lack of clarity about supervision and roles and responsibilities of supervisors, there are now explicit statements about what is expected at all levels of postgraduate training. At foundation level, General Medical Council (GMC) and Postgraduate Medical Education and Training Board (PMETB) standards require that supervision is in place to ensure that foundation doctors are ‘fit for purpose’. At specialist trainee level, health care organizations are required to recognize supervised training as a core responsibility; the Gold Guide (2008) states that such supervision both ensures patient safety and promotes workforce development (i.e. has an educational function). All trainees must have a named educational and clinical supervisor for each rotation; at times the same individual can fulfil both roles but the different roles and responsibilities must be clearly defined (Boxes 1 and 2). GP Associates-in-Training should normally have one educational supervisor for the 3 years and that supervisor will be based in general practice.
Role of educational supervisor
Educational supervisors are responsible for overseeing training to ensure that trainees are making the necessary clinical and educational progress.
Educational supervisors should
be adequately prepared for the role and have an understanding of educational theory and practical educational techniques, e.g. have undertaken formal facilitated training or an online training programme or participate in relevant training (the trainers programmes) be trained to offer educational supervision and undertake review and feedback undertake training in competence assessment for speciality training be trained in equality and diversity provide regular review opportunities that should take place at the beginning, middle and end of a placement develop a learning agreement and educational objectives with the trainee that is mutually agreed and is the point of reference for future review be responsible for ensuring that trainees whom they supervise maintain and develop their speciality learning portfolio and participate in the speciality assessment process provide regular feedback to the trainee on their progress ensure that the structured report, which is a detailed review and synopsis of the trainee's learning portfolio, is returned within the necessary timescales contact the employer (usually the medical director) and the postgraduate dean should the level of performance of a trainee give rise for concern be able to advise the trainee about access to career management be responsible for their educational role to the programme director and locally to the employer's lead for postgraduate medical education
What is supervision for?
It is generally agreed that the two main purposes of supervision are to ensure patient safety and to promote professional development. Supervision is often said to have three functions—educational, supportive and managerial, although there are debates about the managerial function of supervision.
Role of clinical supervisor
Each trainee should have a named clinical supervisor for each placement, usually a senior doctor, who is responsible for ensuring that appropriate clinical supervision of the trainee's day to day clinical performance occurs at all times, with regular feedback.
All clinical supervisors should
understand their responsibilities for patient safety be fully trained in the specific area of clinical care offer a level of supervision necessary to the competences and experience of the trainee and tailored for the individual trainee ensure that no trainee is required to assume responsibility for or perform clinical, operative or other techniques in which they have insufficient experience and expertise ensure that trainees only perform tasks without direct supervision when the supervisor is satisfied that they are competent to do so; both trainee and supervisor should at all times be aware of their direct responsibilities for the safety of patients in their care consider whether it is appropriate (particularly out of hours) to delegate the role of clinical supervisor to another senior member of the health care team. In these circumstances, the individual must be clearly identified to both parties and understand the role of the clinical supervisor. The named clinical supervisor remains responsible and accountable overall for the care of the patient and the trainee. be appropriately trained to teach, provide feedback and undertake competence assessment to trainees in the speciality be trained in equality and diversity and human rights best practice
In some of the literature about supervision, there is a tendency for supervisory relationships to be idealized and for the realities of practice to be ignored. Some authors argue that because trust is important for the development of the supervisory relationship then there can be no managerial or hierarchical relationship and that the content of the supervisory relationship must be confidential. However, in medicine, and arguably all health care professions, there is a managerial aspect to all supervisory relationships and confidentiality is never absolute if there is a risk of harm. Indeed, the Gold Guide makes it clear that supervision, review and performance review are linked.
What is effective supervision?
A number of studies have shown that lack of supervision has a direct negative impact on patient care and can be associated with increased mortality and morbidity (see Kilminster et al., 2007, for a summary). Clearly, the content of what needs to be supervised and the level of supervision will vary according to the grade and relevant experience of the trainee. Supervisors must make judgements as to whether they should be present in the same room as the person being supervised, providing direct supervision; nearby and immediately available to come to the aid of the person being supervised; in the hospital or primary care premises and available at short notice, able to offer immediate help by telephone and able to come to the aid of the person within a short time (local supervision) or on-call and available for advice and able to come to the trainee's assistance in an appropriate time (distant supervision). When we (Grant et al., 2003) asked supervisors and trainees about the type and frequency of activities that occur in supervision, we found that supervision practices are highly variable.
These supervisors and trainees agreed that discussing individual patients is the most frequent and the most effective supervisory activity (see Box 3). However, supervisors and trainees have different perceptions about the amount and type of supervision that trainees receive (trainees generally report receiving less supervision than supervisors report giving). There was general agreement that good supervision is dependent on
The attitudes and commitment of the trainee and supervisor The quality of the supervisory relationship The importance of direct supervision The importance of feedback Protected time for supervision meetings Regular meetings
Supervision activities (in decreasing order of coverage)
Discuss individual patients Ensure patient safety Provide informal feedback Monitor the trainee's performance Discuss (away from the bedside) the management of specific disorders Ensure that the trainee has an appropriate level and amount of clinical duties Provide feedback through review Give advice relevant to personal and professional development Give support relevant to personal and professional development Address successes/problems in trainee performance Give career development advice Develop teamwork skills Ensure the safety of the trainee Discuss/review the process of supervision Teach specific techniques and procedures Plan the trainee's learning Develop interpersonal skills Develop communication skills Develop presentation skills Bedside teaching Use video-taped consultations
There was also general agreement that effective supervisors
Involve trainees in patient care Establish ‘good’ relationships Give direction and constructive feedback Allow procedural opportunities Offer chances to review patients Give trainees responsibility
The following problems with supervision were identified:
Lack of supervision for emergency and ‘out-of-hours’ work Failure to address underperformance Lack of commitment to supervision Lack of time
Supervision in practice
In practice, supervision is much more complex than the literature suggests. There is often a tension in clinical education between enabling trainees to have opportunities for practice and protecting patients; supervisors have to make continual decisions about the activities they can entrust trainees to carry out and the level of supervision those trainees require. In addition, the ‘supervisee’ can become the supervisor at different times in the same day and have to make those same decisions about others. Levels of responsibility and supervision also vary depending on time (out-of-hours), setting, speciality, local practices and cultures and previous experience.
Membership of clinical teams continually changes and lines of responsibility are not always clear and can change; for instance, on some occasions, such as night-time emergencies, the most junior doctor in the team might be the most senior present, and the normal hierarchical and power relations are disrupted for the sake of patient safety. Trainees may be reluctant to ask for help or try to hide specific gaps in their knowledge or experience because they may be (justifiably) concerned about how they are perceived and assessed.
The classic view of clinical supervision is that it is primarily about direct guidance from experts. There is empirical evidence that such guidance is far too infrequent, and even where guidance is given, there is little or no feedback. Feedback tends to be critical rather than constructive, and trainees may avoid seeking out such direct guidance as a result (e.g. Kennedy et al., 2009). In clinical settings, the demands of service delivery mean that trainees' activities cannot always be sequenced from less to more complex. Although the evidence shows that patient care suffers when trainees are unsupervised, some trainees claim to benefit from the experience that lack of supervision gives them. Furthermore, unsupervised experience can lead to the acceptance of lower standards of care because the trainee may not learn the most appropriate practice without supervision. On the other hand, in some supervisory and clinical settings, aspects of the knowledge and practice available to the trainee are inappropriate because supervisors are out of date or have poor practices. Central issues for trainees (and supervisors) therefore include recognizing one's own limits, as well as those of others; knowing when—and being able—to ask for help; dealing with conflicts between their own and supervisors' understandings.
The role of other health professionals—nurses, pharmacists, allied health professionals—in supervision is crucial but frequently ignored. For example, the pharmacist who queries a prescription or the nurse who suggests a course of action to a trainee through their own actions is supervising the trainee. Clearer recognition of this would help trainees feel more supported in clinical practice. If you are not convinced, think of a specific experience of ‘good’ supervision. What was the setting? What was the clinical team like? What happened when your supervisor was not physically present? What did you do if you needed help or advice? What was the ‘atmosphere’ like?
So supervision is integral, not separate, to clinical activity. It is determined by the practices and cultures in particular settings and is not solely dependent on the individual attributes of supervisor and trainee—in other words, supervision is context specific. Current theoretical understandings about learning in workplaces suggest that learning is part of work activity, not separate from it, and this suggests new directions for both practice and research in supervision.
Key points
Current guidance states that educational supervisors are responsible for overseeing training and clinical supervisors are responsible for overseeing day to day clinical practice The purpose of supervision is to ensure patient safety and promote professional development or learning Levels of responsibility and supervision vary depending on time (out-of-hours), setting, speciality, local practices and cultures and previous experience There is some empirically based guidance about effective supervision that can help trainees and supervisors develop their practices It is very important to recognize that supervision is not limited to supervisor-trainee dyads but very significantly affected by activity, practices and cultures of each specific setting Supervision is an integral part of clinical activity, not separate from it