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

Fostering the clinician as teacher: A realist review

BACKGROUND

Clinician-teachers, physicians with educational responsibilities in either classroom or clinical setting, are assumed to add value by virtue of their dual role. The clinical responsibilities are often prioritised over the educational tasks. How and under which circumstances clinician-teachers are able to perform their educational role and create added value for different stakeholders is currently unclear.

OBJECTIVES

To identify for whom, how and under which circumstances educational activities executed by CTs by virtue of their dual role add value to others.

SCOPE

CTs activities linking the system of education and clinical practice beyond direct patient interactions and purposefully executed.

METHODS

A realist review was conducted. Databases were searched in two stages: a narrow conventional search, followed by a comprehensive artificial intelligence-aided search. Studies concerning clinician-teachers' dual role were included. Realist analysis was applied to identify in which contexts resource mechanisms triggered reasoning mechanisms, which led to specific outcomes for different stakeholders.

RESULTS

Sixty-six studies were included. In contexts where clinician-teachers' dual role was formally recognised and valued, clinician-teachers benefitted from the credibility and legitimacy bestowed on them, making the transfer of domain-specific knowledge more impactful. In contexts where sociocultural differences between both systems existed, CTs were able to mediate and adjust recommendations aligned with stakeholders' perceived relevance. Also, contexts organised to support both roles made resource mechanisms more impactful. Clinician-teachers added value to students' clinical competency and learning environment, and to educational organisations' curricular innovation. In their clinical workspace, clinician-teachers added value by enhancing colleague physicians' teaching expertise, implementing educational innovations and recruiting students for scarce specialisms.

CONCLUSION

Clinician-teachers add value to students, colleague physicians and the clinical and educational contexts at large. Domain-specific knowledge of both systems was important to gain credibility and achieve added value. Openness, formal recognition and allocated time for both roles in educational and clinical contexts towards the dual role are important to strengthen the impact of the dual role.

Mentoring as a complex adaptive system - a systematic scoping review of prevailing mentoring theories in medical education

BACKGROUND

Effective mentorship is an important component of medical education with benefits to all stakeholders. In recent years, conceptualization of mentorship has gone beyond the traditional dyadic experienced mentor-novice mentee relationship to include group and peer mentoring. Existing theories of mentorship do not recognize mentoring's personalized, evolving, goal-driven, and context-specific nature. Evidencing the limitations of traditional cause-and-effect concepts, the purpose of this review was to systematically search the literature to determine if mentoring can be viewed as a complex adaptive system (CAS).

METHODS

A systematic scoping review using Krishna's Systematic Evidence-Based Approach was employed to study medical student and resident accounts of mentoring and CAS in general internal medicine and related subspecialties in articles published between 1 January 2000 and 31 December 2023 in PubMed, Embase, PsycINFO, ERIC, Google Scholar, and Scopus databases. The included articles underwent thematic and content analysis, with the themes identified and combined to create domains, which framed the discussion.

RESULTS

Of 5,704 abstracts reviewed, 134 full-text articles were evaluated, and 216 articles were included. The domains described how mentoring relationships and mentoring approaches embody characteristics of CAS and that mentorship often behaves as a community of practice (CoP). Mentoring's CAS-like features are displayed through CoPs, with distinct boundaries, a spiral mentoring trajectory, and longitudinal mentoring support and assessment processes.

CONCLUSION

Recognizing mentorship as a CAS demands the rethinking of the design, support, assessment, and oversight of mentorship and the role of mentors. Further study is required to better assess the mentoring process and to provide optimal training and support to mentors.

Occupying liminal spaces: The figured worlds of student affairs senior leaders in the United States

INTRODUCTION

Student Affairs Senior Leaders (SASLs) in the United States lead offices responsible for academic advising, administrative documentation, scheduling, student health, financial aid, and transition to residency, yet they infrequently draw attention in the field's literature. We explore the role of SASLs and how they describe the social space of medical education.

METHODS

Using a constructivist approach informed by Figured Worlds theory, we conducted a sequential narrative and thematic analysis of the stories SASLs tell about their roles and experiences in the world of medical education.

RESULTS

SASLs inhabit complex roles centred on advocating for medical students' academic, personal and social well-being. Their unique position within the medical school allows them to see the harm to vulnerable students made possible by misalignments inherent within medical education. Yet even with the challenges inherent in the environment, SASLs find reasons for hope.

CONCLUSION

SASLs' identities are full of potential contradictions, but they have a unique view into the often-chaotic world of medical education.

Fragilising clients: A positioning analysis of identity construction during clinical psychology trainees' supervision

CONTEXT

Western mental healthcare system reforms prioritise person-centred care and require clinicians to adjust their professional positions. Realising these reforms will necessitate clinicians-including clinical psychologists-acquiring professional identities that align with them. Learners develop professional identities through socialisation activities: within interactional spaces such as supervision learners come to understand the self (clinician) and, by extension, the other (client). A clinician's understanding of who I am is intertwined with an understanding of who they are. Our study offers a moment-by-moment examination of supervision interactions of clinical psychology trainees to illuminate processes through which the identities of therapists and clients are constructed.

AIM

We examined how clinical psychology trainees and supervisors construct identities for themselves and clients in supervision.

METHODS

We used positioning analysis to explore identity construction during interactions between supervisors (n = 4) and trainees (n = 12) in a clinical psychology training clinic. Positioning analysis focuses on the linguistic choices participants make as they position themselves (and others) in certain social spaces during everyday interactions. Twelve supervision sessions were audio recorded and transcribed. We found that clients were frequently positioned as fragile and subsequently analysed these sequences (n = 12).

RESULTS

Clients' identities were constructed as fragile, which co-occurred with clinical psychologists' claiming positions as responsible for managing their distress. Supervisors played an active role in linguistically positioning clients and trainees in this way. Trainees rarely contested the identities made available to them by supervisors.

DISCUSSION AND CONCLUSION

We suggest that linguistically positioning clients as fragile perpetuates paternalistic clinical discourses that do not align with mental healthcare reform priorities. We make visible how this is achieved interactionally through language and influenced by organisational power relations. Intentional efforts are required to support the professional identity construction of clinical psychologists in ways that do not perpetuate paternalism. We offer recommendations for education and clinical practice to support these efforts.

What students say to be ready for acute care: Implications for preceptors

BACKGROUND

Student readiness for clinical education experiences is an important variable for clinical preceptors. Readiness has been reported from the viewpoints of clinicians, academic faculty, clinical preceptors, employers and novice graduate physical therapists. Perspectives from physical and occupational therapy students could better prepare preceptors in the acute care setting.

APPROACH

Thematic analysis was conducted following the approach described by Braun and Clarke. The purpose of this study was to describe physical and occupational therapy student perceptions of readiness for full-time acute care clinical education experiences. Twenty-one physical and occupational therapy students in process of completing full-time clinical education experiences at a large academic medical centre were qualitatively interviewed in small groups. A two-stage iterative process of thematic inquiry was used to induce themes about student readiness for full-time acute care clinical experiences. Transcription, coding and thematic analysis were completed. Students also completed a one-time questionnaire with demographic and learner characteristic scales.

FINDINGS

Participants were on average 26.4 years old, predominantly female and White, and had completed one full-time clinical education experience prior to participation. Four major thematic categories of student readiness for acute care clinical experiences emerged: (1) mindset and willingness; (2) knowledge and experience; (3) communication and collaboration; and (4) planning and prioritising.

IMPLICATIONS

Students report their readiness is facilitated by preceptors who can model flexibility, foster communication that promotes clinical reasoning, implement an orientation to the acute care culture and learning resources and scaffold roles and responsibilities to aid professional authority.

The figured world of medical education senior leaders: Making meaning and enacting agency

INTRODUCTION

The field of medical education is relatively new, and its boundaries are not firmly established. If we had a better understanding of the intricacies of the domain, we might be better equipped to navigate the ever-changing demands we must address. To that end, we explore medical education as a world wherein leaders harness agency, improvisation, discourse, positionality and power to act.

METHODS

Using the constructivist theory of figured worlds (FW), we conducted a narrative analysis of the stories medical education senior leaders tell about their roles and experiences in the world of medical education (n = 9).

RESULTS

We identified four foundational premises about the world of medical education: (i) medical education stands at the intersection of three interrelated worlds of clinical medicine, hospital administration and university administration; (ii) medical education is shaped by and shapes the clinical learning environment at the local level; (iii) medical education experiences ubiquitous change which is a source of power; and (iv) medical education is energised by relationships between individuals.

DISCUSSION

Focusing on the FW theory's notions of agency, improvisation, discourse, positionality and power enabled us to describe the world of medical education as a complex domain existing in a space of conflicting power hierarchies, identities and discourses. Using FW allowed us to see the powerful affordances offered to medical education due to its position between worlds amid unceasing change.

Which 'end' do you have in mind? Clinical supervisors' perceptions of professional Identity Formation outcomes in GP residency

PURPOSE

Professional Identity Formation (PIF) is crucial for high-quality patient care and physician well-being. Few empirical studies examined PIF in residency from the perspective of supervisors. In GP residency, residents are supervised with an 'end in mind' that remains unexplored. To encourage supervisors to reflect on their teaching behaviours, this study investigated GP clinical supervisors' perceptions of PIF outcomes in GP residency.

METHODS

Applying qualitative description, focus group interviews were conducted between spring and autumn 2019. Using a semi-structured interview guide, supervisors' perceptions of PIF outcomes were explored. In an iterative coding process applying constant comparison, a thematic analysis was performed of focus group transcripts.

RESULTS

We conducted eight focus groups with 55 supervisors at four training institutes across the Netherlands. Half of the supervisors were female. GP supervisors tend to address the 'poor GP' when prompted to address the 'good GP'. PIF outcomes in GP residency should revolve around taking ownership in patient care, self-care and the persistence of GP as a profession.

CONCLUSION

PIF can be challenged by a lack of positive language. Supervisors' strong beliefs regarding ideals of the profession potentially compromise PIF when they do not resonate with residents' beliefs, resulting in poor educational alliance.

"What kind of doctor do you want to become?": Clinical supervisors' perceptions of their roles in the professional identity formation of General Practice residents

PURPOSE

Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in residency, and little is known about supervisors' perceptions of their roles in residents' PIF. In this study, we sought to understand how supervisors perceive their roles in the PIF of General Practice (GP) residents.

MATERIALS AND METHODS

Guided by principles of qualitative description, we conducted eight focus groups with 55 supervisors at four General Practice training institutes across the Netherlands. Informed by a conceptual framework of PIF, we performed a thematic analysis of focus group transcripts.

RESULTS

Three themes related to how GP supervisors described their roles in supporting residents' PIF: supervising with the desired goal of GP training in mind; role modeling and mentoring as key strategies to achieve that goal; and the value of developing bonds of trust to support the process.

CONCLUSIONS

To our knowledge, this study is the first to explore PIF in GP training from the perspective of clinical supervisors. The identified themes mirror the components of the therapeutic alliance between doctors and patients from a supervisor's perspective and highlight the pivotal roles of the supervisor in a resident's PIF.

Learning in a real-life escape room: an explorative study on the supervisory relationship in GP residency during the COVID-19 pandemic

BACKGROUND

The relationship between supervisors and residents plays a prominent role in the professional development of general practice (GP) residents. When disruptions occur in the normal course of healthcare, due to effects of e.g. war or emerging epidemics, we need to consider how this may affect the training of the next generation of general practitioners. As both supervisors and residents face new and unprecedented challenges that impact overall quality of the training. In this study, we examined the characteristics of the supervisory relationship in GP training during the disruptions early on during COVID-19. Our aim was to understand better how resident learning is affected in these circumstances, which is a first step in enabling supervisors, residents and faculty to anticipate disruptive situations better in the future.

METHODS

We conducted a qualitative case study with a constructivist approach. Seven GP residents at the start of their second placement, and their 10 supervisors participated in this study. Participants came from a University Medical Centre in the Netherlands. Semi-structured interviews were held between September 2020 and February 2021. The subjects were (1) interviewed individually about what they had learned regarding COVID-19, and (2) they were interviewed in supervisory pairs about how they had learned. Data were iteratively analysed; thematic analysis for (1) and template analysis in (2).

RESULTS

We identified notable changes in the supervisor-resident relationship attributable to COVID-19. Supervisors and residents were confronted with an all-encompassing uncertainty in the workplace, and disruptive changes in patient care and learning opportunities for residents. Supervisors and residents addressed these emerging workplace challenges through three types of collaboration, (1) getting the job done; (2) residents' learning; and (3) collective learning. Each type had a different focus and distinctive characteristics of the supervisory relationship.

CONCLUSION

With the outbreak of COVID-19, supervisors and residents were faced with disruptive uncertainty. In these circumstances, learning occurred not only between residents and their supervisors, but also with non-supervising GPs and assistants in collective learning. We propose to complement collective learning in the workplace with reflection between residents and supervisors at the training institution.

Interrogation in clinical supervision sessions: Exploring the construction of clinical psychology trainees’ professional identities

BACKGROUND

Professional socialisation is a complex process through which learners become healthcare professionals. This process occurs in relational spaces: learners are exposed to norms and expectations of them in interactions during formal and informal learning activities. Research exploring socialisation into the healthcare professions is extensive yet inadequately captures details of the actual processes of socialisation and forming of professional identity. Our study offers a moment-by-moment examination of clinical psychology trainee supervision to provide a deeper exploration of novice healthcare professionals' identity development within formal educational interactions.

AIMS

We sought to explore how, and in what ways, supervision interactions impact clinical psychology trainees' professional identity development.

METHOD

Our data comprises 12 audio recordings of supervisor-trainee interactions in a clinical psychology training clinic. Initial data engagement identified 20 instances of interrogation instigated by supervisors (i.e., repetitive questioning, enquiry) as being key events in which identities are contested and re-negotiated. These sections were transcribed verbatim. Drawing on positioning, framing and impression management theories, we explored identity construction in interrogations using discourse analysis.

RESULTS

Supervisors approached interrogations of trainees from either a quality control or a reflective frame focusing on the client or trainee respectively. These frames influenced the positions being made available to trainees. Reflective frame interrogations often defaulted back to quality control. Trainees employed impression management tactics to manage perceived face-threat.

DISCUSSION

Findings highlight challenges with maintaining a reflective space in supervision during interrogations. Supervisors had authority to initiate interrogations that could be taken up, negotiated or resisted by trainees, ultimately maintaining certain professional knowledge and truths. We illuminate the ways in which socialisation processes at the interactional level during formal learning activities ultimately make available (and restrict) certain ways for trainees to think, feel and be.

Development and validity evidence for the intraprofessional conflict exercise: An assessment tool to support collaboration

BACKGROUND

Effective collaboration is the foundation for delivering safe, high quality patient care. Health sciences curricula often include interprofessional collaboration training but may neglect conflicts that occur within a profession (intraprofessional). We describe the development of and validity evidence for an assessment of intraprofessional conflict management.

METHODS AND FINDINGS

We designed a 22-item assessment, the Intraprofessional Conflict Exercise, to evaluate skills in managing intraprofessional conflicts based on a literature review of conflict management. Using Messick's validity framework, we collected evidence for content, response process, and internal structure during a simulated intraprofessional conflict from 2018 to 2019. We performed descriptive statistics, inter-rater reliability, Cronbach's alpha, generalizability theory, and factor analysis to gather validity evidence. Two trained faculty examiners rated 82 trainees resulting in 164 observations. Inter-rater reliability was fair, weighted kappa of 0.33 (SE = 0.03). Cronbach's alpha was 0.87. The generalizability study showed differentiation among trainees (19.7% person variance) and was highly reliable, G-coefficient 0.88, Phi-coefficient 0.88. The decision study predicted that using one rater would have high reliability, G-coefficient 0.80. Exploratory factor analysis demonstrated three factors: communication skills, recognition of limits, and demonstration of respect for others. Based on qualitative observations, we found all items to be applicable, highly relevant, and helpful in identifying how trainees managed intraprofessional conflict.

CONCLUSIONS

The Intraprofessional Conflict Exercise provides a useful and reliable way to evaluate intraprofessional conflict management skills. It provides meaningful and actionable feedback to trainees and may help health educators in preparing trainees to manage intraprofessional conflict.

The role of mentoring, supervision, coaching, teaching and instruction on professional identity formation: a systematic scoping review

BACKGROUND

Mentoring's pivotal role in nurturing professional identity formation (PIF) owes much to its combined use with supervision, coaching, tutoring, instruction, and teaching. However the effects of this combination called the 'mentoring umbrella' remains poorly understood. This systematic scoping review thus aims to map current understanding.

METHODS

A Systematic Evidence-Based Approach guided systematic scoping review seeks to map current understanding of the 'mentoring umbrella' and its effects on PIF on medical students and physicians in training. It is hoped that insights provided will guide structuring, support and oversight of the 'mentoring umbrella' in nurturing PIF. Articles published between 2000 and 2021 in PubMed, Scopus, ERIC and the Cochrane databases were scrutinised. The included articles were concurrently summarised and tabulated and concurrently analysed using content and thematic analysis and tabulated. The themes and categories identified were compared with the summaries of the included articles to create accountable and reproducible domains that guide the discussion.

RESULTS

A total of 12201 abstracts were reviewed, 657 full text articles evaluated, and 207 articles included. The three domains identified were definitions; impact on PIF; and enablers and barriers. The mentoring umbrella shapes PIF in 3 stages and builds a cognitive base of essential knowledge, skills and professional attitudes. The cognitive base informs thinking, conduct and opinions in early supervised clinical exposure in Communities of practice (COP). The COPs' individualised approach to the inculcation of desired professional characteristics, goals, values, principles and beliefs reshapes the individual's identity whilst the socialisation process sees to their integration into current identities.

CONCLUSION

The mentoring umbrella's provides personalised longitudinal support in the COP and socialisation process. Understanding it is key to addressing difficulties faced and ensuring holistic and timely support.

General practice residents’ perspectives on their professional identity formation: a qualitative study

Objectives

To move beyond professionalism as a measurable competency, medical educators have highlighted the importance of forming a professional identity, in which learners come to ‘think, act, and feel like physicians’. This socialisation process is known as professional identity formation (PIF). Few empirical studies on PIF in residency have been undertaken. None of these studies focused on PIF during the full length of GP training as well as the interplay of concurrent socialising factors. Understanding the socialisation process involved in the development of a resident’s professional identity and the roles of influencing factors and their change over time could add to a more purposeful approach to PIF. Therefore, we aimed to investigate the process of PIF during the full length of General Practice (GP) training and which factors residents perceive as influential.

Design

A qualitative descriptive study employing focus group interviews.

Setting

Four GP training institutes across the Netherlands.

Participants

Ninety-two GP residents in their final training year participated in 12 focus group interviews.

Results

Study findings indicated that identity formation occurs primarily in the workplace, as residents move from doing to becoming and negotiate perceived norms. A tapestry of interrelated influencing factors—most prominently clinical experiences, clinical supervisors and self-assessments—changed over time and were felt to exert their influence predominantly in the workplace.

Conclusions

This study provides deeper empirical insights into PIF during GP residency. Doing the work of a GP exerted a pivotal influence on residents’ shift from doing as a GP to thinking, acting and feeling like a GP, that is, becoming a GP. Clinical supervisors are of utmost importance as role models and coaches in creating an environment that supports residents’ PIF. Implications for practice include faculty development initiatives to help supervisors be aware of how they can perform their various roles across different PIF stages.

Twelve tips for teaching and supervising post-graduate trainees in clinic

By providing quality teaching and supervision, medical educators can contribute to productive and fulfilling outpatient experiences for postgraduate trainees (sometimes called residents, registrars, or GP trainees). The recent literature addressing practical steps to improve outpatient teaching is limited. Here we present specific trainee-centric behaviors, techniques, and language that educators can employ to enhance their teaching in the outpatient clinic, in the form of twelve tips. The first two tips pertain to navigating the patient-trainee-supervisor dynamic in the exam room, the next four address listening to an oral presentation, and the last six are tips on being an effective teacher and coach.

The social construction of teacher and learner identities in medicine and surgery

INTRODUCTION

There are growing concerns about the quality and consistency of postgraduate clinical education. In response, faculty development for clinical teachers has improved formal aspects such as the assessment of performance, but informal work-based teaching and learning have proved intractable. This problem has exposed a lack of research into how clinical teaching and learning are shaped by their cultural contexts. This paper explores the relationship between teacher-learner identity, educational practice and the workplace educational cultures of two major specialties: internal medicine and surgery.

METHODS

This was a secondary analysis of a large dataset, comprising field notes, participant interviews, images and video-recordings gathered in an ethnographic study. The lead author embedded himself in four clinical teams (two surgical and two medical) in two different hospitals. The authors undertook a critical reanalysis of the observational dataset, using Dialogism and Figured Worlds theory to identify how teachers and postgraduate learners figured and authored their professional identities in the specialty-specific cultural worlds of surgery and internal medicine.

RESULTS

Surgery and internal medicine privileged different ways of being, knowing and talking in formal and informal settings, where trainees authored themselves as capable practitioners. The discourse of surgical education constructed proximal coaching relationships in which trainees placed themselves at reputational risk in a closely observed, embodied practice. Internal medicine constructed more distal educational relationships, in which trainees negotiated abstract representations of patients' presentations, which aligned to a greater or lesser degree with supervisors' representations.

CONCLUSIONS

Our research suggests that clinical education and the identity positions available to teachers and learners were strongly influenced by the cultural worlds of individual specialties. Attempts to change work-based learning should be founded on situated knowledge of specialty-specific clinical workplace cultures and should be done in collaboration with the people who work there, the clinicians.

Student perspectives of extended clinical placements in optometry: a qualitative study

BACKGROUND

The number of students enrolled in health courses at Australian universities is rising, increasing demand for clinical placements. Optometry students have historically undertaken clinical training in short-block rotations at university-led teaching clinics in metropolitan locations. This is changing, with some optometry programs adopting extended placements. These placements are conducted in community-based practices, with many incorporating a rural component to the training. This study explored factors which influence placement success and satisfaction from the perspective of optometry students.

METHODS

Nine focus groups were undertaken with 42 final year optometry students upon completion of a 26-week placement (of which at least half was undertaken in a non-metropolitan area, or area where a shortage of optometrists has been identified). Focus groups were audio recorded and transcribed verbatim. Thematic analysis was conducted according to Braun and Clarke's 6 step method.

RESULTS

Four key themes were identified during analysis. 'Changing identity', related to how the students grew both personally and professionally, with the extended placement being considered the vital component that allowed students to begin thinking of themselves as clinicians. The theme 'Dealing with complex dynamics and circumstances' predominantly described instances where the student-supervisor relationship was strained, resulting in high levels of anxiety made worse by a perceived lack of university support. 'Optometrist under instruction', related to students feeling that the placement was an ideal opportunity to trial the everyday reality of work without the obligation of an ongoing commitment or employment contract. Finally, the theme 'Rural practice is more rewarding', was about a chance to seek different experiences, meet new people and challenge themselves professionally.

CONCLUSION

While the majority of students enjoyed their placement and felt that it was the key component of their training that equipped them for future practice, it is clear that universities and placement providers must provide both students and supervisors thorough and explicit guidance covering placement expectations. Furthermore, student support systems should be embedded into placement programs to ensure where issues arise, they are dealt with promptly and successfully. It is vital that ongoing professional development and pedagogical training for supervisors underpins continued accreditation.

Towards equitable learning environments for medical education: Bias and the intersection of social identities

CONTEXT

Medical educators are increasingly paying attention to how bias creates inequities that affect learners across the medical education continuum. Such bias arises from learners' social identities. However, studies examining bias and social identities in medical education tend to focus on one identity at a time, even though multiple identities often interact to shape individuals' experiences.

METHODS

This article examines prior studies on bias and social identity in medical education, focusing on three social identities that commonly elicit bias: race, gender and profession. By applying the lens of intersectionality, we aimed to generate new insights into intergroup relations and identify strategies that may be employed to mitigate bias and inequities across all social identities.

RESULTS

Although different social identities can be more or less salient at different stages of medical training, they intersect and impact learners' experiences. Bias towards racial and gender identities affect learners' ability to reach different stages of medical education and influence the specialties they train in. Bias also makes it difficult for learners to develop their professional identities as they are not perceived as legitimate members of their professional groups, which influences interprofessional relations. To mitigate bias across all identities, three main sets of strategies can be adopted. These strategies include equipping individuals with skills to reflect upon their own and others' social identities; fostering in-group cohesion in ways that recognise intersecting social identities and challenges stereotypes through mentorship; and addressing intergroup boundaries through promotion of allyship, team reflexivity and conflict management.

CONCLUSIONS

Examining how different social identities intersect and lead to bias and inequities in medical education provides insights into ways to address these problems. This article proposes a vision for how existing strategies to mitigate bias towards different social identities may be combined to embrace intersectionality and develop equitable learning environments for all.

Increased professionalization and lower burnout scores were associated with structured residency training program: results of a cross sectional survey

The competence centre for Residency Training in Family Medicine Bavaria (CCRTB) was established to improve the quality of postgraduate medical education by offering training and mentoring programmes for residents, and by providing train-the-trainer and mentoring courses for supervisors. Beyond that, regional Residency Training Networks (RTN) on avoluntary basis were developed to facilitate structured and efficient clinical rotation programs. Primary aim was to investigate the burden of burnout and the development of professionalism among CCRTB-residencies within a cross-sectional study. Secondary aim was to evaluate differences between CCRTB-residents with and without participation in aregional RTN. Burnout was determined with the Maslach Burnout Inventory (MBI), comprising the scales emotional exhaustion, depersonalization, and personal accomplishment. Ambulatory professionalization was evaluated using the German Professional Scale (Pro-D), comprising the scales professionalism towards the patient, towards other professionals, towards society, and towards oneself. Statistical significance of group differences was calculated by nonparametric tests. Multivariable linear regression modelling was performed to estimate the independent impact of professionalization and RTN participation on burnout scores. 347 CRRTB residents in ambulatory postgraduate training were invited, 212 (61.1%) participated, and 197 (92.9%) were included in our analyses. Lower emotional exhaustion and depersonalization, and increased personal accomplishment was associated with increased professionalisation, which was significant for nearly all Pro-D scales (p ≤ 0.05). RTN residents showed higher professionalism towards the patient (p = 0.031), other professionals (p = 0.012), and towards the society (p = 0.007) than residents of unstructured programs, and higher levels of personal accomplishment (p < 0.05). Early and efficient professionalization might be akey to reduce burnout and to establish asatisfying career in family medicine. Train-the-trainer and mentoring concepts should be implemented regularly for the training of residents. Thus, increased engagement in medical didactics should be aprerequisite for accreditation as atraining practice for residents.

'Nurses whisper.' Identities in nurses' patient safety narratives of nurse-trainee doctors' interactions

CONTEXT

Nurses are integral to patient safety, but little is known about their narrative constructions of identity in relation to their dyadic interactions with trainee doctors about patient safety and competence during the trajectory of a medical career.

AIM

We sought to examine how identities are constructed by experienced nurses in their narratives of patient safety encounters with trainee doctors.

METHODS

Our qualitative study gathered narrative data through semi-structured interviews with nurses of different professional standing (n = 20). Purposive sampling was used to recruit the first eight participants, with the remainder recruited through theoretical sampling. Audio recordings were transcribed verbatim and analysed inductively through a social constructionist framework and deductively using a competence framework.

RESULTS

We classified seven identities that participants constructed in their narratives of dyadic interactions with trainee doctors in relation to patient safety: nurses as teacher, guardian of patient wellbeing, provider of emotional support, provider of general support, expert advisor, navigator and team player. These identities related to the two key roles of nurses as educators and as practitioners. As they narrated these dyadic interactions, participants constructed identities that positioned trainee doctors in character tropes, suggesting gaps in professional competence: nurses as provider of general support was commonly narrated in the context of perceived deficits of personal or functional capabilities and nurses as team player was mainly associated with concerns (or reassurances) around ethical capabilities.

DISCUSSION AND CONCLUSION

Our findings are consistent with, and extend the wider literature on the development of professional competence, interprofessional collaboration in health care, and the nature and organisation of nursing work. Nurses' work in ensuring patient safety and support trainee doctors' professional development merits greater formal recognition and legitimation.

Getting good help: a guide for reflection, debriefing and feedback conversations about in-consultation supervision

Timely supervisor input to the care of their trainees' patients plays a key role in ensuring the safety of patients under the care of general practice trainees. Supervisor responses to trainee calls for assistance are also important for trainee learning and professional identity formation. The in-consultation supervisory encounter in general practice training is, however, a complex social space with multiple trainee, supervisor and patient agendas. Trainee requests for assistance during their consultations are known to present general practitioner supervisors with a number of challenges. From the trainee's perspective, a safe learning environment is essential during these supervisory interactions. A number of factors may act as barriers to, or reduce the usefulness of, in-consultation assistance in particular, resulting in trainees being less likely to seek such assistance on future occasions. It is therefore important to improve both trainee and supervisor skills in safe, effective and efficient in-consultation supervision. Making time for trainee and supervisor conversations about their help-seeking and help provision may uncover opportunities for improving skills, aligning agendas and enhancing outcomes. Finding time for debriefing, reflection and effective feedback conversations may be challenging, however, and opportunities for trainees to provide feedback to their supervisors are known to be particularly limited. We introduce a Debriefing, Reflection and Feedback Guide which is designed to prompt reflection, and structure effective and efficient debriefing and reciprocal feedback conversations. We outline the evidence which informed the development of the Guides, and present some preliminary findings from a pilot in Australian general practice training.

Good help: a model for providing in-consultation supervision of general practice trainees

Timely clinical supervision of trainee consultations plays a key role in ensuring the safety of patients under the care of general practice trainees, and in trainee learning and professional development. Trainee requests for assistance during their consultations present supervisors with a number of challenges, however, and a number of factors act as barriers to, or reduce the utility of, this in-consultation assistance from the trainee's perspective. Face-to-face supervision in the presence of the patient presents particular challenges and opportunities. It is important to address barriers to trainee help-seeking and improve both trainee and supervisor skills in promoting safe, effective and efficient in-consultation supervision. We introduce a model (β-LACTAM) to assist supervisors in planning and delivering their face-to-face in-consultation supervision. The recent evidence which informed the development of this model is outlined, and some preliminary findings from a pilot of β-LACTAM in Australian general practice training are presented.