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Jackson D, Brady J, Dawkins D. Positioning, power and agency in postgraduate primary care supervision: a study of trainee narratives. BMC MEDICAL EDUCATION 2023; 23:880. [PMID: 37978527 PMCID: PMC10656937 DOI: 10.1186/s12909-023-04826-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Postgraduate supervision takes place within complex training environments, where experiences are shaped by the socio-cultural context and wider profession, and where tensions permeate. Bordin's working alliance-based model of supervision suggests that quality relationships encompass agreement on the goals and tasks of supervision, in the context of an emotional bond. However, as trainees and their supervisors navigate the demands of providing safe clinical care, alongside educational support, disagreement on expectations for supervision may emerge. By applying a critical lens, this research draws on positioning theory to explore General Practice trainees' experiences of supervision. METHODS In 2017-2019 a series of narrative interviews were undertaken with 13 General Practice trainees in the United Kingdom (UK). Participants were purposively sampled based on end-of-year performance, gender, training location and training status. Interviews were analysed using Brown and Gilligan's Listening Guide, which was adapted to incorporate an exploration of positioning, power and agency. RESULTS Trainees appeared to hold variable positions, such as 'insiders', 'outsiders', 'peers' and 'problem trainees'. Supervisors, through talk and the degree of access afforded, contributed to this positioning. Some trainees viewed their supervisors as brokers and guides as they navigated their training, whilst others were suspicious of the supervisor role. For trainees who raised concerns about their supervisor through formal channels, results were not often satisfactory. Others chose to navigate difficulty in supervision through informal means. This typically involved mastery of artefacts of training, such as the electronic appointment book or training portfolio. CONCLUSIONS This paper builds on Bordin's model of supervision to encourage greater clarity in supervisory discussions, exploring assumptions, and recognising the influences of environment, power, positioning, and agency. We have developed a Model of the Supervisory Alliance in Postgraduate GP Training (MSA-GP) to serve as a springboard for discussion for trainees and their supervisors.
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Affiliation(s)
- Dawn Jackson
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Josephine Brady
- Mary Immaculate College, South Circular Road, Limerick, V94 VN26, Ireland
| | - Donna Dawkins
- School of Education, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Rothwell C, Kehoe A, Farook SF, Illing J. Enablers and barriers to effective clinical supervision in the workplace: a rapid evidence review. BMJ Open 2021; 11:e052929. [PMID: 34588261 PMCID: PMC8479981 DOI: 10.1136/bmjopen-2021-052929] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES We aimed to review the international literature to understand the enablers of and barriers to effective clinical supervision in the workplace and identify the benefits of effective clinical supervision. DESIGN A rapid evidence review. DATA SOURCES Five databases (CINAHL, OVID Embase, OVID Medline, OVID PsycInfo and ProQuest) were searched to ensure inclusion and breadth of healthcare professionals. ELIGIBILITY CRITERIA Studies identifying enablers and barriers to effective clinical supervision across healthcare professionals in a Western context between 1 January 2009 and 12 March 2019. DATA EXTRACTION AND SYNTHESIS An extraction framework with a detailed inclusion/exclusion criteria to ensure rigour was used to extract data. Data were analysed using a thematic qualitative synthesis. These themes were used to answer the research objectives. RESULTS The search identified 15 922 papers, reduced to 809 papers following the removal of duplicates and papers outside the inclusion criteria, with 135 papers being included in the full review. Enablers identified included regular supervision, occurs within protected time, in a private space and delivered flexibly. Additional enablers included supervisees being offered a choice of supervisor; supervision based on mutual trust and a positive relationship; a cultural understanding between supervisor and supervisee; a shared understanding of the purpose of supervision, based on individual needs, focused on enhancing knowledge and skills; training and feedback being provided for supervisors; and use of a mixed supervisor model, delivered by several supervisors, or by those trained to manage the overlapping (and potentially conflicting) needs of the individual and the service. Barriers included a lack of time, space and trust. A lack of shared understanding to the purpose of the supervision, and a lack of ongoing support and engagement from leadership and organisations were also found to be barriers to effective clinical supervision. CONCLUSIONS This review identified several enablers of and barriers to effective clinical supervision and the subsequent benefits of effective clinical supervision in a healthcare setting.
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Affiliation(s)
- Charlotte Rothwell
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Amelia Kehoe
- Health Professions Education Unit, Hull York Medical School, York, UK
| | - Sophia Farhene Farook
- Emergency Medicine, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Jan Illing
- Health Professions Education Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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O’Sullivan B, Hickson H, Kippen R, Wallace G. Exploring attributes of high-quality clinical supervision in general practice through interviews with peer-recognised GP supervisors. BMC MEDICAL EDUCATION 2021; 21:441. [PMID: 34416905 PMCID: PMC8376628 DOI: 10.1186/s12909-021-02882-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/10/2021] [Indexed: 05/27/2023]
Abstract
BACKGROUND Clinical supervision in general practice is critical for enabling registrars (GP trainees) to provide safe medical care, develop skills and enjoy primary care careers. However, this largely depends on the quality of supervision provided. There has been limited research describing what encompasses quality within GP clinical supervision, making it difficult to promote best practice. This study aimed to explore the attributes of high-quality clinical supervision for GP registrars. METHODS In 2019-20, 22 semi-structured interviews were conducted with GP supervisors who were peer-nominated as best practice supervisors, by Regional GP Training Organisations and GP Colleges in Australia. Purposeful sampling sought respondents with diverse characteristics including gender and career stage, practice size, state/territory and rurality. Interviews were conducted by video-consultation and recorded. De-identified transcripts were independently coded using iterative, inductive thematic analyses to derive themes that reflected quality in GP supervision. RESULTS Seven themes emerged. Participants understood the meaning of quality supervision based on their experience of being supervised when they were a registrar, and from reflecting and learning from other supervisors and their own supervision experiences. Quality was reflected by actively structuring GP placements to optimise all possible learning opportunities, building a secure and caring relationship with registrars as the basis for handling challenging situations such as registrar mistakes. Quality also encompassed sustaining and enhancing registrar learning by drawing on the input of the whole practice team who had different skills and supervision approaches. Strong learner-centred approaches were used, where supervisors adjusted support and intervention in real-time, as registrar competence emerged in different areas. Quality also involved building the registrar's professional identity and capabilities for safe and independent decision-making and encouraging registrars to reflect on situations before giving quality feedback, to drive learning. CONCLUSIONS This study, although exploratory, provides a foundation for understanding the quality of clinical supervision in general practice, from the perspective of peer-recognised GP supervisors. Understanding and adopting quality within GP supervision may be improved by GPs sharing exemplars of best practice and having opportunities for professional reflection. The findings could be used as a point of reference for devising GP supervisor curriculum, resources and professional development activities.
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Affiliation(s)
- Belinda O’Sullivan
- General Practice Supervisors Australia, PO Box 141, Bendigo North, Victoria 3550 Australia
- Rural Clinical School, Faculty of Medicine, University of Queensland, Locked Bag 9009, Toowoomba, Queensland 4350 Australia
- School of Rural Health, Monash University, PO Box 666, Bendigo, Victoria 3550 Australia
| | - Helen Hickson
- General Practice Supervisors Australia, PO Box 141, Bendigo North, Victoria 3550 Australia
- La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, Victoria 3550 Australia
| | - Rebecca Kippen
- School of Rural Health, Monash University, PO Box 666, Bendigo, Victoria 3550 Australia
| | - Glen Wallace
- General Practice Supervisors Australia, PO Box 141, Bendigo North, Victoria 3550 Australia
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Winter R, Norman RI, Patel R. A qualitative exploration of the lived experience of GP trainees failing to progress in training. EDUCATION FOR PRIMARY CARE 2020; 32:10-18. [PMID: 33232197 DOI: 10.1080/14739879.2020.1831970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Challenges facing general practice are multiple and extreme. Amongst them is the increasing difficulty of recruiting and retaining General Practitioners (GPs). GPs cite heavy workload, work-related stress, little family time and psychological ill-health as factors influencing their decisions to leave or reduce working hours. Analysis of the literature suggests that these factors, amongst others, are present in GP training and trainees have similar experiences. An in-depth understanding of the challenges trainees in difficulty face is lacking.Our research aim was to better understand the factors that trainees perceive contribute to their failure to progress in training. A qualitative approach was adopted using semi-structured interviews with GP trainees identified as failing to progress satisfactorily or failing the MRCGP examinations. Interviews were audio-recorded and transcribed. Thematic analysis was used to understand the unique experiences of GP trainees and find common themes.Twenty-three interview transcripts were analysed. Emergent themes were presented using a framework of three distinct categories to aid data organisation and allocating themes and sub-themes: professional factors, personal factors, and social factors. Difficulties with managing work-load, poor motivation, lack of family time and psychological ill-health were significant themes for many. This study supports the evidence that difficulties facing GPs take root in training. Failure to fully understand trainees' journeys and associated challenges reduces opportunities to provide bespoke packages of care and remediation that fully address their needs.
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Affiliation(s)
- Rachel Winter
- College of Life Sciences, University of Leicester, Leicester, UK
| | - Robert I Norman
- College of Life Sciences, University of Leicester, Leicester, UK
| | - Rakesh Patel
- Medical Education, University of Nottingham, Nottingham, UK
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Ahluwalia S, Spicer J, Patel A, Cunningham B, Gill D. Understanding the relationship between GP training and improved patient care - a qualitative study of GP educators. EDUCATION FOR PRIMARY CARE 2020; 31:145-152. [PMID: 32106783 DOI: 10.1080/14739879.2020.1729252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Previous research has highlighted the benefits of receiving care in a postgraduate GP training practice including improved patient satisfaction, more appropriate secondary care usage, cancer diagnosis, and antibiotic prescribing. Whilst the influence of being registered in a postgraduate GP training practice on patient outcomes is modest relative to other factors such as deprivation, disease burden, demography, and ethnicity, the reasons for this benefit is not clear. AIM This study explores how GP trainers perceive engagement with clinical education influences patient care. METHODS Socio-cultural theories were used as a framework for guiding the research. Semi-structured interviews were conducted with 11 GP educators. Interviews were recorded and transcribed verbatim. Data analysis involved thematic analysis. RESULTS GP educators identified four overarching themes that, for them, seemed to explain how clinical education mediates its influence on patient care. These included: influencing through (i) educational leadership; (ii) learners; (iii) the educational process; and (iv) educational standards. DISCUSSION Findings suggest that GP trainees have a significant effect on the learning environment, professional development of GP trainers, and patient care. The nature of the relationship between GP trainers and trainees appears far more bilateral than acknowledged in the apprenticeship model.
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Affiliation(s)
| | | | | | - Bryan Cunningham
- Department of Education, Practice and Society, Institute of Education, University College London , London, UK
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Jackson D, Davison I, Adams R, Edordu A, Picton A. A systematic review of supervisory relationships in general practitioner training. MEDICAL EDUCATION 2019; 53:874-885. [PMID: 31074063 DOI: 10.1111/medu.13897] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/22/2019] [Accepted: 03/20/2019] [Indexed: 05/14/2023]
Abstract
OBJECTIVES The educational alliance is argued to be at the heart of supervision in medical education. This review aims to map the research field and develop a conceptualisation of the nature of such educational alliances within postgraduate supervision for general practitioners. METHODS An integrative review of the international literature on supervision from 2011 to 2018 was undertaken, and papers assessed for relevance and quality. Data analysis incorporated framework analysis techniques. Bordin's working alliance-based model of supervision was used as a springboard for synthesis, as well as allowing for the emergence of new ideas, theories and concepts from the literature. RESULTS A total of 49 full texts were included for analysis. There was evidence of the importance of trust, agreement and bond in accordance with Bordin's model. The results also highlighted the importance of greater clarity on supervisory goals, and the tasks to support these goals, to effectively address competing priorities and roles within supervision. Non-hierarchical relationships were advocated, although supervisors must remain impartial in their assessment and monitoring roles. The influence of the wider practice community and situated learning through legitimate peripheral participation are documented. A model of General practice (GP) supervision is proposed that integrates the findings. CONCLUSIONS GP supervision requires a greater emphasis than is suggested by the working alliance model, both on the clarity of expectations and the appreciation of the multiple roles and competing priorities of both trainee and supervisor. Furthermore, as GP supervision develops within the rising workload of contemporary general practice, the role of the wider community of practice may become more prominent. We have adapted the working alliance model for postgraduate General practice (GP) supervision, emphasising the explicit sharing of expectations relating to goals, tasks and roles to facilitate negotiation and agreement.
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Affiliation(s)
- Dawn Jackson
- Medical School, University of Birmingham, Birmingham, UK
| | - Ian Davison
- School of Education, University of Birmingham, Birmingham, UK
| | - Rachel Adams
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Adaeze Edordu
- Primary Care and Health Sciences, University of Keele, Keele, UK
| | - Aled Picton
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Hawkridge A, Molyneux D. A description and evaluation of an educational programme for North West England GP trainees who have multiple fails in the Clinical Skills Assessment (CSA). EDUCATION FOR PRIMARY CARE 2019; 30:167-172. [PMID: 30724714 DOI: 10.1080/14739879.2019.1570476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Anne Hawkridge
- SOX Programme, Health Education England North West, Manchester, UK
| | - David Molyneux
- SOX Programme, Health Education England North West, Manchester, UK
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Jackson D, Davison I, Brady J. The tacit rules of the game in the GP trainee–trainer supervisory relationship: experienced educators describe GP supervision. EDUCATION FOR PRIMARY CARE 2018; 29:278-285. [DOI: 10.1080/14739879.2018.1501769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
| | - Ian Davison
- School of Education, University of Birmingham, Birmingham, UK
| | - Josephine Brady
- School of Education, University of Birmingham, Birmingham, UK
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Christensen MK, O’Neill L, Hansen DH, Norberg K, Mortensen LS, Charles P. Residents in difficulty: a mixed methods study on the prevalence, characteristics, and sociocultural challenges from the perspective of residency program directors. BMC MEDICAL EDUCATION 2016; 16:69. [PMID: 26907611 PMCID: PMC4763408 DOI: 10.1186/s12909-016-0596-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 02/16/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND The majority of studies on prevalence and characteristics of residents in difficulty have been conducted in English-speaking countries and the existing literature may not reflect the prevalence and characteristics of residents in difficulty in other parts of the world such as the Scandinavian countries, where healthcare systems are slightly different. The aim of this study was to examine prevalence and characteristics of residents in difficulty in one out of three postgraduate medical training regions in Denmark, and to produce both a quantifiable overview and in-depth understanding of the topic. METHODS We performed a mixed methods study. All regional residency program directors (N = 157) were invited to participate in an e-survey about residents in difficulty. Survey data were combined with database data on demographical characteristics of the background population (N = 2399) of residents, and analyzed statistically (Chi-squared test (Χ (2)) or Fisher's exact test). Secondly, we performed a qualitative interview study involving three focus group interviews with residency program directors. The analysis of the interview data employed qualitative content analysis. RESULTS 73.2 % of the residency program directors completed the e-survey and 22 participated in the focus group interviews. The prevalence of residents in difficulty was 6.8 %. We found no statistically significant differences in the prevalence of residents in difficulty by gender and type of specialty. The results also showed two important themes related to the workplace culture of the resident in difficulty: 1) belated and inconsistent feedback on the resident's inadequate performance, and 2) the perceived culturally rooted priority of efficient patient care before education in the workplace. These two themes were emphasized by the program directors as the primary underlying causes of the residents' difficulty. CONCLUSIONS More work is needed in order to clarify the link between, on the one hand, observable markers of residents in difficulty and, on the other hand, immanent processes and logics of practice in a healthcare system. From our perspective, further sociological and pedagogical investigations in educational cultures across settings and specialties could inform our understanding of and knowledge about pitfalls in residents' and doctors' socialization into the healthcare system.
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Affiliation(s)
- Mette K. Christensen
- />Centre for Health Sciences Education, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Lotte O’Neill
- />Centre for Health Sciences Education, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Dorthe H. Hansen
- />Centre for Health Sciences Education, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Karen Norberg
- />Northern Postgraduate Medical Training Region Secretariat, Skottenborg 26, 8800 Viborg, Denmark
| | | | - Peder Charles
- />Centre for Health Sciences Education, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
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