Improving undergraduate clinical supervision in a South African context
Faculty of Health Sciences, University of Stellenbosch
Correspondence to: Elize Archer (firstname.lastname@example.org)
Objectives: The Faculty of Health Sciences, Stellenbosch University, has undergraduate programmes for several disciplines; these programmes need clinical supervisors to teach their students in the clinical settings. The faculty does not have the resources to present different clinical supervision courses for each discipline; therefore a short course with an interprofessional focus was designed.
Design: A qualitative study was done to determine the strengths and weaknesses of the course in order to re-curriculate as deemed necessary. Semi-structured individual interviews were held with 10 (n=18) course participants as well as the tutors involved in the development of the course. Ethical approval was obtained. Participation was voluntary and anonymity was guaranteed. The recorded and transcribed data were analysed.
Setting: The health professionals acting as supervisors may be the experts in their fields, but they do not always have the necessary teaching skills. The Centre for Health Sciences Education (CHSE) at the faculty has developed a generic short course in undergraduate clinical supervision to address the above issue.
Results and conclusion: The data were used to inform restructuring of the short course for the following year. The impact of this short course on clinical supervisors was that their interaction with students in the clinical setting improved. There was unanimous support for extending the short course to all clinical supervisors. The lecturers involved in developing the course were positive about the interprofessional cooperation among colleagues and students. They emphasised that the Faculty of Health Sciences has an obligation to provide opportunities for clinical supervisors to improve their skills to supervise students.
The Faculty of Health Sciences (FHS) at Stellenbosch University (SU) offers undergraduate programmes for several disciplines. All these programmes need clinical supervisors to teach undergraduate students in the clinical settings. Although most clinical teachers are enthusiastic and take their role as teachers of future generations of healthcare professionals seriously, they often lack knowledge of educational principles and teaching strategies and thus may be inadequately prepared for this additional professional role.1,2 According to the literature it is clear that clinicians do not become teachers by virtue of their medical expertise, but a reflective approach to teaching and professional development can foster excellence in clinical teaching.3 Due to new methods of teaching and learning, a more student-centred approach to teaching, competency-based assessment and emphasis on aspects such as professionalism, educators today are required to have an expanded toolkit of teaching skills and clinical experience.4 Staff development can provide clinicians with new knowledge and skills about teaching and learning and it can also reinforce or alter attitudes or beliefs about education.3,5 Increasingly educational providers require their clinical teachers to undertake some form of basic teacher training.2 These training programmes might differ from informal short courses to master’s or doctoral degrees in health sciences education. Research shows that the act of teaching facilitates an improved level of knowledge for the teacher compared to self-study or lecture attendance. Furthermore, it revealed that residents’ job satisfaction is augmented by teaching duties.6
A short course in clinical supervision was designed and implemented at the Faculty of Health Sciences as an attempt to increase the standard of clinical supervision of undergraduate students. The faculty does not have the resources to present different clinical supervision courses for each discipline; therefore a short course with an interdisciplinary focus was designed. The course consists of one contact session of 8 hours where a study guide is provided for self-study. Within 6 weeks of attending this contact session students have to submit an assignment reflecting on a recently performed clinical supervision session. A certificate is awarded after the completion of the course. The awarding of continuous professional development (CPD) points on completion of the course serves as an additional incentive. The course covers topics such as the roles of the clinical educator; how adults learn; learning in a clinical environment; techniques of facilitating learning, assessment and feedback to students.
After the first course was presented a qualitative study was done to determine the strengths and weaknesses of the course in order to re-curriculate if deemed necessary.
Semi-structured individual interviews were held with 10 (n=16) course participants (supervisors) as well as the five lecturers involved in the development of the course. The course participants that were interviewed were purposively sampled with reference to the clinical sites where they worked; e.g. hospitals, private practices or community health centres, their years of experience, professions as well as their availability. None of the participants has done any formal courses in education before. Amongst them were five occupational therapists (n=6), four physiotherapists (9) and one medical doctor (n=1). The years of teaching students in the clinical areas ranged between 1 and 21 years, with most of them less than 3 years.
The semi-structured interviews were done by an independent person at the clinical sites of the course participants and lasted about 1 hour each. Some of the questions that were explored during the interviews were participants’ motivation to do the course; whether the assignment was relevant; use of new teaching skills after the course and confidence when teaching. The interviews were recorded and the transcribed data were analysed by the researcher as well as a second Health Sciences Educator. The data were coded and recurring themes were identified. Ethical approval was obtained for the study. Participation was voluntary and anonymity was guaranteed.
Key themes that emerged from the interviews are presented below. (Some of the quotations from participants that are used in the section below were translated from Afrikaans to English.)
Motivation to attend the short course
Supervisors attended the course for various reasons, for example they felt inadequately equipped when they had to supervise students.
Felt lost when supervising the students.
Some of them were new to student supervision while one was interested in furthering an academic career. The motivational impact of CPD points can also not be disregarded.
The CPD points were a good motivator to work through the course.
Applicability of the course to the clinical context
The content of the course seemed to be appropriate to the needs of the course participants. Their confidence to transfer the new teaching skills varied from being ready to implement new teaching techniques immediately to a more cautious approach where more information was required.
Especially the teaching techniques that were discussed were valuable, I think I can use them next time.
Usefulness of the short course’s study guide
Supervisors reported that they have read almost all the prescribed articles, which they found sufficient. Only two participants read some of the recommended literature. Most of them agreed that they preferred a hard copy study guide with all the notes and articles rather than electronic access to the same.
I like to make notes on the hard copies.
Relevance of the assignment
All the participants reported the relevance of the assignment with reference to their context and that completing the assignment assisted them in thinking clearly about how they were fulfilling their role as supervisors.
I thought the assignment was relevant; it made you think a bit outside the box and what other teaching methods I could also use.
Some supervisors felt encouraged in realising that their teaching skills were often in line with recommended strategies.
Improved interaction with students
Interaction with the students and insight into the student/supervisor relationship were markedly improved. It was clear that some of the supervisors did not always follow a structured approach to clinical teaching.
I use to wing things as I went along, but now I have a structured plan for the clinical rotation.
Almost all of the supervisors indicated that they now make use of teaching strategies that they have never used before.
The half-day course was changed to a full day after the participants recommended that they would have preferred more time for the discussion of the topics. Detailed guidelines for the assignment were included in the study guide after the participants requested more specific instructions.
Did not completely understand what was needed for the assignment.
Lecturers’ general opinions
The lecturers involved in the design and presentation of the course were very enthusiastic about the course. They were all positive about the interdisciplinary cooperation amongst colleagues and students. They emphasised that the faculty has an obligation to provide opportunities for clinical supervisors to improve their skills to supervise students and to have a better understanding of adult learning.
I think it is very unfair of universities to expect outside people to assist with the teaching of students without assisting them.
The participants who attended the course were of the opinion that this short course is vitally important in our institution if we want the quality of clinical supervision to improve in the clinical areas. This opinion is in line with other studies done with healthcare providers.6
The participants’ motivation to attend the short course was mainly intrinsic; supervisors who have a passion for their work were keen to attend and further their knowledge. As far as faculty development is concerned, the challenge lies in the process of convincing all clinical supervisors of undergraduate students to attend this course. For teachers to succeed at their teaching tasks, faculty development is essential.4
Although CPD points can be an added motivator, ironically most of the motivated supervisors seem to have earned their quota of CPD points even before they attended the course. There could have been a degree of bias in the study group firstly because they do not represent all professions, and secondly because it could be that those who attended the course may be more enthusiastic about teaching than those who did not attend the course. The technique used in this study to evaluate the course participants’ improvement in teaching skills, namely self-reflection, is not regarded as a very rigorous evaluation method, according to Post et al.,7 and future studies looking at this same issue would attempt to use more rigorous methods such as direct observation and videotape of the participants before and after the course.
The majority of participants who were interviewed for the research had less than 3 years’ teaching experience. One could therefore argue that young clinical supervisors still have a lot to learn. It would be recommended that in a next research study more senior lecturers/clinicians be interviewed and asked the same questions. In a critical review of residents-as-teachers curricula it is suggested that a study population of 40 residents from all training years should be used to give a study enough power to show a significant effect of the teaching intervention.7
According to Bursari et al.8 the development of teacher-training programmes is a rather complicated issue, mainly because of logistical problems such as irregular working hours, and the support of important stakeholders such as training boards and cooperation of staff. When designing such a course it is vital to ensure that the content and length of the course are very specific to the needs of the supervisors. In a critical review that was done to determine the most evidence-based curricula and evaluation strategy used in residents’ curricula it was found that the mean length of the teaching courses was 7.6 hours and that the most common intervention was based on the One-Minute Preceptor.8 In our course we included the One-Minute Preceptor9 as well as other teaching methods/ techniques to address the teaching needs of the variety of professions all attending the same course. Course participants reported in their feedback that the interprofessional nature of the course was refreshing and that the teaching strategies that were discussed would be applicable to their different contexts.
Due to the fact that the course consists only of one contact day it seems very important that the study guide has to provide the course participants with all the relevant information. The assignment at the end of the course needs to have clear instructions and be relevant in order to empower the supervisors for their clinical teaching opportunities. Some of the course participants reported that having to do reflection about a teaching intervention in to write up the assignment was valuable in the sense that they had to stop and think what they were doing.
The presentation of the course in an interprofessional manner seems to have many advantages, amongst others the realisation that supervisors from different professions share common challenges and frustrations regarding the teaching of students.
Demonstrating that a particular supervisory intervention has a direct effect on patient/client care is extremely difficult. Consequently researchers have attempted to examine the effects of supervisor on the trainee/student.10 Our study is an example of the perceptions of supervisors about their teaching skills and behaviours after attending a short course in clinical supervision. Some of the pronounced quantitative evidence in the literature shows that supervision can have an effect on patient outcome and that the lack of supervision is harmful to patients. Clinical supervision with input from a supervisor seems to facilitate skills development more rapidly than unsupervised clinical sessions.7
There was unanimous support from all the course participants to extend the short course to all clinical supervisors. If this is not done supervisors could be inclined to apply the same teaching methods which they experienced when they were undergraduate students. However, teaching workshops can provide clinicians with new knowledge and skills about teaching and learning .3,4
This study adds to the body of knowledge in this field by confirming the need for faculty development of clinical supervisors in our South African context. A follow-up study that is currently being undertaken is looking at the impact of the course, including supervisors’ behaviour before and after the course as well as students’ feedback regarding the teaching strategies of the clinical supervisors.
A word of appreciation to the interdisciplinary course development team as well as to M van Heusden for conducting the interviews and proofreading this article. The research was funded by the Fund for Innovation and Research into Learning and Teaching (FIRLT) Stellenbosch University, South Africa.
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