Ad hoc supervision of general practice registrars as a 'community of practice': analysis, interpretation and re-presentation

The impact of online education during the Covid-19 pandemic on the professional identity formation of medical students: A systematic scoping review

Evolving individual, contextual, organizational, interactional and sociocultural factors have complicated efforts to shape the professional identity formation (PIF) of medical students or how they feel, act and think as professionals. However, an almost exclusive reliance on online learning during the COVID-19 pandemic offers a unique opportunity to study the elemental structures that shape PIF and the environmental factors nurturing it. We propose two independent Systematic Evidence-Based Approach guided systematic scoping reviews (SSR in SEBA)s to map accounts of online learning environment and netiquette that structure online programs. The data accrued was analysed using the clinically evidenced Krishna-Pisupati Model of Professional Identity Formation (KPM) to study the evolving concepts of professional identity. The results of each SSR in SEBA were evaluated separately with the themes and categories identified in the Split Approach combined to create richer and deeper 'themes/categories' using the Jigsaw Perspective. The 'themes/categories' from each review were combined using the Funnelling Process to create domains that guide the discussion. The 'themes/categories' identified from the 141 included full-text articles in the SSR in SEBA of online programs were the content and effects of online programs. The themes/categories identified from the 26 included articles in the SSR in SEBA of netiquette were guidelines, contributing factors, and implications. The Funnelling Process identified online programs (encapsulating the content, approach, structures and the support mechanisms); their effects; and PIF development that framed the domains guiding the discussion. This SSR in SEBA identifies the fundamental elements behind developing PIF including a structured program within a nurturing environment confined with netiquette-guided boundaries akin to a Community of Practice and the elemental aspect of a socialisation process within online programs. These findings ought to be applicable beyond online training and guide the design, support and assessment of efforts to nurture PIF.

Positioning, power and agency in postgraduate primary care supervision: a study of trainee narratives

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.

Assessing the effects of a mentoring program on professional identity formation

BACKGROUND

Medical education has enjoyed mixed fortunes nurturing professional identity formation (PIF), or how medical students think, feel and act as physicians. New data suggests that structured mentoring programs like the Palliative Medicine Initiative (PMI) may offer a means of developing PIF in a consistent manner. To better understand how a well-established structured research mentoring program shapes PIF, a study of the experiences of PMI mentees is proposed.

METHODOLOGY

Acknowledging PIF as a sociocultural construct, a Constructivist approach and Relativist lens were adopted for this study. In the absence of an effective tool, the Ring Theory of Personhood (RToP) and Krishna-Pisupati Model (KPM) model were used to direct this dual Systematic Evidence-Based Approach (Dual-SEBA) study in designing, employing and analysing semi-structured interviews with PMI mentees and mentoring diaries. These served to capture changes in PIF over the course of the PMI's mentoring stages. Transcripts of the interviews and mentoring diaries were concurrently analysed using content and thematic analysis. Complementary themes and categories identified from the Split Approach were combined using the Jigsaw Approach and subsequently compared with mentoring diaries in the Funnelling Process. The domains created framed the discussion.

RESULTS

A total of 12 mentee interviews and 17 mentoring diaries were analysed, revealing two domains-PMI as a Community of Practice (CoP) and Identity Formation. The domains confirmed the centrality of a structured CoP capable of facilitating longitudinal mentoring support and supporting the Socialisation Process along the mentoring trajectory whilst cultivating personalised and enduring mentoring relationships.

CONCLUSION

The provision of a consistent mentoring approach and personalised, longitudinal mentoring support guided along the mentoring trajectory by structured mentoring assessments lay the foundations for more effective mentoring programs. The onus must now be on developing assessment tools, such as a KPM-based tool, to guide support and oversight of mentoring relationships.

Contribution of supervision to the development of advanced practitioners: a qualitative study of pharmacy learners' and supervisors' views

OBJECTIVE

To apply educational theory to explore how supervision can contribute to the development of advanced practitioners using the example of several postregistration primary care training pathways for pharmacy professionals (pharmacists and pharmacy technicians).

DESIGN

Qualitative semistructured telephone interviews applying Billet's theory of workplace pedagogy for interpretation.

SETTING

England.

PARTICIPANTS

Fifty-one learners and ten supervisors.

PRIMARY OUTCOME

Contribution of clinical and educational supervision to the development of advanced practitioners in primary care.

RESULTS

Findings were mapped against the components of Billet's theory to provide insights into the role of supervision in developing advanced practitioners. Key elements for effective supervision included supporting learners to identify their learning needs (educational supervision), guiding learners in everyday work activities (clinical supervision), and combination of regular prearranged face-to-face meetings and ad hoc contact when needed (clinical supervision), along with ongoing support as learners progressed through a learning pathway (educational supervision). Clinical supervisors supported learners in developing proficiency and confidence in translating and applying the knowledge and skills they were gaining into practice. Learners benefited from having clinical supervisors in the workplace with good understanding and experience of working in the setting, as well as receiving clinical supervision from different types of healthcare professionals. Educational supervisors supported learners to identify their learning needs and the requirements of the learning pathway, and then as an ongoing available source of support as they progressed through a pathway. Educational supervisors also filled in some of the gaps where there was a lack of local clinical supervision and in settings like community pharmacy where pharmacist learners did not have access to any clinical supervision.

CONCLUSIONS

This study drew out important elements which contributed to effective supervision of pharmacy advanced practitioners. Findings can inform the education and training of advanced practitioners from different professions to support healthcare workforce development in different healthcare settings.

Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning

Australian general practice trainees typically consult with patients from their first week of training, seeking in-consultation supervisory assistance only when not sufficiently confident to complete patient consultations independently. Trainee help-seeking plays a key role in supervisor oversight of trainee consultations. This study used focus groups and interviews with general practice supervisors to explore their approaches to trainee help-seeking and in-consultation supervision. Supervisor approaches are discussed under three themes: establishing a help-seeking culture; perceptions of in-consultation assistance required; and scripts for help provision. Within these themes, three interwoven entrustment processes were identified: supervisor entrustment; trainee self-entrustment; and 'patient entrustment' (patient confidence in the trainee's clinical management). Entrustment appears to develop rapidly, holistically and informally in general practice training, partly in response to workflow pressure and time constraints. Typical supervisor scripts and etiquette for help-provision involve indirect, soft correction strategies to build trainee self-entrustment. These scripts appear to be difficult to adapt appropriately to under-performing trainees. Importantly, supervisor scripts also promote patient entrustment, increasing the likelihood of patients returning to the trainee and training practice for subsequent review, which is a major mechanism for ensuring patient safety in general practice. Theories of entrustment in general practice training must account for the interplay between supervisor, trainee and patient entrustment processes, and work-related constraints. Gaps between entrustment as espoused in theory, and entrustment as enacted, may suggest limitations of entrustment theory when extended to the general practice context, and/or room for improvement in the oversight of trainee consultations in general practice training.

Becoming a clinician: Trainee identity formation within the general practice supervisory relationship

OBJECTIVES

Becoming a clinician is a trajectory of identity formation in the context of supervised practice. This is a social process where the supervisory relationship is key. Therefore, to know how to support identity formation of clinical trainees, it is necessary to understand how this happens within the supervisory relationship. Our aim was to develop a conceptualisation of trainee identity formation within the general practice supervisory relationship to aid its support.

METHODS

We took a critical realist approach using case study design and 'cultural worlds' theory as a conceptual frame. Each case comprised a general practice trainee and supervisor pair. Our data were weekly audiorecordings of interactions between trainee, supervisor and a patient over 12 weeks augmented by post-interaction reflections and sequential interviews. We undertook interpretive analysis using dialogic methods focusing on the doing of language and the cultural discourses expressed.

RESULTS

We identified three social discourses centring on: clinical responsibility; ownership of clinical knowledge, and measures of trainee competency. Versions of these discourses defined four trainee-supervisor relational arrangements within which trainee and supervisor assumed reciprocal identities. We labelled these: junior learner and expert clinician; apprentice assistant and master coach, and lead clinician and advisor. We found a trajectory across these identity arrangements. Behind this trajectory was an invitation by the supervisor to the trainee into the social space of clinician and a readiness of the trainee to accept this invitation. Congruence in supervisor and trainee positioning was important.

CONCLUSIONS

In the supervisory relationship, trainee and supervisor adopted reciprocal identities. For trainees to progress to identity of 'lead clinician,' supervisors needed to invite their trainee into this space and vacate it themselves. Congruence between supervisor positioning of their trainee and trainee authorship of themselves was important and was aided by explicit dialogue and common purpose. We offer a model and language for trainees, supervisors and departments or schools to facilitate this.

A systematic review of supervisory relationships in general practitioner training

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.

Disentangling residents' engagement with communities of clinical practice in the workplace

Maximising the potential of the workplace as a learning environment entails understanding the complexity of its members' interactions. Although some articles have explored how residents engage with supervisors, nurses and pharmacists individually, there is little research on how residents enter into and engage with the broader community of clinical practice (CoCP). To this end, we designed a constructivist grounded theory study that took place at Universidad Javeriana in Bogotá, Colombia. We conducted semi-structured interviews with 13 residents from different training levels and disciplines during the first weeks of their new rotations. During the interviews, we used the Pictor technique as a visual aid to collect data. Using iterative data collection and analysis, constant comparison methods and theoretical sampling, we constructed the final results. When entering a CoCP, residents experienced recurring and intertwined processes including: exploring how their goals and interest are aligned with those of the CoCP; identifying the relevant CoCP members in the workplace environment; and understanding how these members could assist their successful engagement with the community's practices. Residents entered a CoCP with the intention of either having a central or a peripheral trajectory in it. The final resident participation and role resulted from negotiations between the resident and the CoCP members. Optimising workplace learning includes being mindful as to how each member of the healthcare team influence residents' engagement on practice, and on understanding the nuances of residents' participatory trajectories while interacting with them. Understanding such nuances could be key to align CoCPs' learning affordances and residents' goals and intentions.

Theory, a lost character? As presented in general practice education research papers

OBJECTIVES

The use of theory in research is reflected in its presence in research writing. Theory is often an ineffective presence in medical education research papers. To progress the effective use of theory in medical education, we need to understand how theory is presented in research papers. This study aims to elicit how theory is being written into general practice (GP) vocational education research papers in order to elucidate how theory might be more effectively used. This has relevance for the field of GP and for medical education more broadly.

METHODS

This is a scoping review of the presentation of theory in GP vocational education research published between 2013 and 2017. An interpretive approach is taken. We frame research papers as a form of narrative and draw on the theories of Aristotle's poetics and Campbell's monomyth. We seek parallels between the roles of theory in a research story and theories of characterisation.

RESULTS

A total of 23 papers were selected. Theories of 'reflective learning', 'communities of practice' and 'adult learning' were most used. Six tasks were assigned to theory: to align with a position; to identify a research problem; to serve as a vehicle for an idea; to provide a methodological tool; to interpret findings, and to represent an object of examination. The prominence of theory in the papers ranged from cameo to major roles. Depending on the way theory was used and the audience, theory had different impacts. There were parallels between the tasks assigned to theory and the roles of four of Campbell's archetypal characters. Campbell's typology offers guidance on how theory can be used in research paper 'stories'.

CONCLUSIONS

Theory can be meaningfully present in the story of a research paper if it is assigned a role in a deliberate way and this is articulated. Attention to the character development of theory and its positioning in the research story is important.

What should we teach the teachers? Identifying the learning priorities of clinical supervisors

Clinicians who teach are essential for the health workforce but require faculty development to improve their educational skills. Curricula for faculty development programs are often based on expert frameworks without consideration of the learning priorities as defined by clinical supervisors themselves. We sought to inform these curricula by highlighting clinical supervisors own requirements through answering the research question: what do clinical supervisors identify as relative strengths and areas for improvement in their teaching practice? This mixed methods study employed a modified version of the Maastricht Clinical Teaching Questionnaire (mMCTQ) which included free-text reflections. Descriptive statistics were calculated and content analysis was conducted on textual comments. 481 (49%) of 978 clinical supervisors submitted their mMCTQs and associated reflections for the research study. Clinical supervisors self-identified relatively strong capability with interpersonal skills or attributes and indicated least capability with assisting learners to explore strengths, weaknesses and learning goals. The qualitative category 'establishing relationships' was the most reported strength with 224 responses. The qualitative category 'feedback' was the most reported area for improvement, with 151 responses. Key areas for curricular focus include: improving feedback practices; stimulating reflective and agentic learning; and managing the logistics of a clinical education environment. Clinical supervisors' self-identified needs provide a foundation for designing engaging and relevant faculty development programs.

The supervisory encounter and the senior GP trainee: managing for, through and with

OBJECTIVE

Help-seeking supervisory encounters provide important learning experiences for trainees preparing for independent practice. Although there is a body of expert opinion and theories on how supervisor encounters should happen, supporting empirical data are limited. This is particularly true for the senior general practice (GP) trainee. Without knowing what happens during these encounters, we cannot know how to maximise their educational potential. This study aimed to understand what happens when senior GP trainees call on their supervisor when caring for patients and how learning can be enhanced when this occurs.

METHODS

This is an analysis of data from a multi-case study of five GP supervisory pairs, each with a GP registrar and their supervisor. The data are recordings of 45 supervisory encounters, 78 post-encounter reflections and six interviews. We used Wenger's communities of practice theory and rhetorical genre theory as analytical lenses.

RESULTS

The supervisory encounters followed a consistent format, which fitted the form of a genre. Within this genre, three dominant interactional patterns were identified, which we labelled 'managing for', 'managing through' and 'managing with'. Each pattern presented different opportunities and drew on different skills. The primary agenda was always developing a plan for the patient. Education agendas included acquiring knowledge, developing skills and achieving independence. Other agendas were issues of control, credibility and relationship building. Both supervisor and trainee could be purposeful in their supervisory engagement.

CONCLUSIONS

For supervisors and trainees to achieve the educational potential of their supervisory encounters they require flexibility. This depends on understanding the genre of the supervisory encounter, the agendas at play, the options they have in engaging and having the skills to utilise these options. Educators can facilitate supervisors and trainees in acquiring this understanding and these skills. We recommend further research into the genre of the supervisory encounter.

Self-entrustment: how trainees' self-regulated learning supports participation in the workplace

Clinical workplaces offer postgraduate trainees a wealth of opportunities to learn from experience. To promote deliberate and meaningful learning self-regulated learning skills are foundational. We explored trainees' learning activities related to patient encounters to better understand what aspects of self-regulated learning contribute to trainees' development, and to explore supervisor's role herein. We conducted a qualitative non-participant observational study in seven general practices. During two days we observed trainee's patient encounters, daily debriefing sessions and educational meetings between trainee and supervisor and interviewed them separately afterwards. Data collection and analysis were iterative and inspired by a phenomenological approach. To organise data we used networks, time-ordered matrices and codebooks. Self-regulated learning supported trainees to increasingly perform independently. They engaged in self-regulated learning before, during and after encounters. Trainees' activities depended on the type of medical problem presented and on patient, trainee and supervisor characteristics. Trainees used their sense of confidence to decide if they could manage the encounter alone or if they should consult their supervisor. They deliberately used feedback on their performance and engaged in reflection. Supervisors appeared vital in trainees' learning by reassuring trainees, discussing experience, knowledge and professional issues, identifying possible unawareness of incompetence, assessing performance and securing patient safety. Self-confidence, reflection and feedback, and support from the supervisor are important aspects of self-regulated learning in practice. The results reflect how self-regulated learning and self-entrustment promote trainees' increased participation in the workplace. Securing organized moments of interaction with supervisors is beneficial to trainees' self-regulated learning.