‘Hands on, hands off’: a model of clinical supervision that recognises trainees’ need for support and independence
Rick Iedema A G , Suzanne Brownhill A , Mary Haines B C , Bill Lancashire D , Tim Shaw E and Jane Street FA Centre for Health Communication, University of Technology Sydney, PO Box 123, Ultimo, NSW 2007, Australia. Email: suzanne.brownhill@uts.edu.au
B Hospital Alliance for Research Collaboration, The Sax Institute, Level 7, Jones Street, Sydney, NSW 2007, Australia. Email: mary.haines@saxinstitute.org.au
C School of Public Health, University of Sydney, Sydney, NSW 2006, Australia.
D Rural Clinical School, University of New South Wales, Port Macquarie Campus at Port Macquarie Base Hospital, Wrights Road, Port Macquarie, NSW 2444, Australia. Email: lancashb@bigpond.net.au
E Workforce Education and Development Group, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia. Email: tim.shaw@sydney.edu.au
F Centre for Workforce Research and Innovation, Sydney West Area Health Service, Wirrabilla Building, Cumberland Hospital Campus, 1-11 Hainsworth Street, Westmead, NSW 2145, Australia. Email: jane.street@swahs.health.nsw.gov.au
G Corresponding author. Email: r.iedema@uts.edu.au
Australian Health Review 34(3) 286-291 https://doi.org/10.1071/AH09773
Submitted: 14 April 2009 Accepted: 3 November 2009 Published: 25 August 2010
Abstract
Rationale. This article presents a study of junior doctor supervision at a rural hospital. The objective of the present study was to gain insight into the types of supervision events experienced, the quality of supervisory relationships, the frequencies of supervision contact in a rural hospital setting, and the implications of these factors for supervision practice.
Methods. A cohort of junior doctors was asked to provide in-depth information about their interactions with their supervisors and other relevant clinical colleagues. The information was filled in on diary sheets to capture the nature, focus and quality of the cohort’s supervision experiences over 2 weeks. The information also covered frequency and types of supervisory contacts.
Results. The quantitative data reveals that supervisory events occur predominantly as part of ongoing patient care and rarely off-line as part of targeted supervisory practice. The qualitative data analysis reveals that junior doctors value supervisory support of two kinds: assistance from more senior clinicians who are expert in areas where trainees need help, and trust to act independently, without being abandoned.
Conclusion. Supervision must be both structured and dynamic. Besides providing a regular forum for discussion and reflection, supervision must accommodate the variable needs of individual junior doctors and navigate between being hands-on and hands-off. Such dynamic approach is necessary to reassure junior doctors they are in a ‘zone of safe learning’ where they can act with adequate and flexible support and negotiate changes in supervisory attention.
What is known about the topic? Research is recognising the challenges of treatment complexity and unexpected outcomes faced by junior doctors. These factors mean that supervision needs to include dealing with the experiential and interpersonal aspects of junior doctors’ clinical work. It is also recognised that the supervisory relationship remains to be investigated in depth. Further, because supervision guidelines in Australia are still under development, they do not as yet specify senior doctors’ or registrar’s supervisory accountabilities. Relying on conventional approaches to managing medical supervision, hospitals and associated medical schools are struggling to ensure that supervising doctors’ perceptions of and approaches to supervision are aligned with emerging definitions of effective supervision.
What does this paper add? The ‘hands on, hands off’ model developed here enriches post-graduate medical curricula on two fronts. First, it advises supervisors that they need to be hands-on, practising ‘active supervision’. This involves regular and structured contact with junior doctors to enhance the safety and quality of the care provided by them. Second, it advises supervisors to be hands-off, practising ‘passive supervision’. This involves ‘trustful’ monitoring junior doctors’ everyday work and negotiating with them their unique and changing learning trajectories.
What are the implications for practitioners? The model proposed here has three implications for practitioners. First, the model posits that medical supervision is about ‘being there’. Junior doctors set great store by being granted ready access to advice and help if and when that is needed. Second, the model emphasises that junior doctors expect to gain supervisors’ trust to act independently albeit with supervisory access and guidance being readily available. Third, junior doctors’ needs change, not necessarily in a linear, uni-directional way. For supervisors, this means that they need to devise regular feedback opportunities for their trainees to articulate their developments, concerns and changing needs.
Acknowledgements
This research was made possible thanks to financial contributions from the NSW Institute of Medical Education and Training, North Coast Area Health Service, and the Hospital Alliance for Research Collaboration, a program at the Sax Institute. We acknowledge the generous participation of the following people: Port Macquarie Base Hospital Junior Medical Officers PGY1–3 (November–December 2008 cohort); Port Macquarie Base Hospital Registrars; Port Macquarie Base Hospital Clinical Supervisors; Dr Michael King, Director of Medical Services, Port Macquarie Base Hospital; Ms Cathy Pullen, JMO Manager, PMBH; Roger Kerr, PMBH; John Agland, Manager, Reporting Unit, Demand and Performance Evaluation; and NSW Department of Health.
[1] Baldwin PJ, Dodd M, Wrate RM. Junior doctors making mistakes. Lancet 1998; 351(9105): 804.
| Crossref | GoogleScholarGoogle Scholar | PubMed | CAS | [verified 3 August 2010].
[4]
[5]
[6]
[7]
[8] Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Med Educ 2000; 34(10): 827–40.
| Crossref | GoogleScholarGoogle Scholar | PubMed | CAS |
[9] Cottrell D, Kilminster S, Jolly B, Grant J. What is effective supervision and how does it happen? A critical incident study. Med Educ 2002; 36(11): 1042–9.
| Crossref | GoogleScholarGoogle Scholar | PubMed |
[10]
[11] Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? Qual Saf Health Care 2003; 12(3): 221–6.
| Crossref | GoogleScholarGoogle Scholar | PubMed | CAS |
[12]
[13] White AA, Gallagher TH, Krauss MJ, Garbutt J, Waterman AD, Dunagan WC, Fraser VJ, Levinson W, Larson EB. The attitudes and experiences of trainees regarding disclosing medical errors to patients. Acad Medi 2008; 83(3): 250–6.
| Crossref | GoogleScholarGoogle Scholar | PubMed |
[14]
[15] Todd G, Freshwater D. Reflective practice and guided discovery: clinical supervision. Br J Nurs 1999; 8(20): 1383–9.
| PubMed | CAS |
[16] Paget T. Reflective practice and clinical outcomes: practitioners’ views on how reflective practice has influenced their clinical practice. J Clin Nurs 2001; 10(2): 204–14.
| Crossref | GoogleScholarGoogle Scholar | PubMed | CAS |
[17] Sithamparanathan M. That’s all I got handed over. BMJ 2006; 332(7539): 496.
| Crossref | GoogleScholarGoogle Scholar |
[18] Madigosky WS, Headrick LA, Nelson K, Cox KR, Anderson T. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med 2006; 81(1): 94–101.
| Crossref | GoogleScholarGoogle Scholar | PubMed |
[19]
[20]
[21]
[22] Iedema R, Jorm C, Lum M. Affect is central to patient safety: the horror stories of young anaesthetists. Soc Sci Med 2009; 69(12): 1750–6.
| Crossref | GoogleScholarGoogle Scholar | PubMed |
A PGY1 and PGY2 are Post-Graduate Years 1 and 2. These are the first 2 years of doctor trainees’ full-time employment in a clinical role.
