A systematic review of supervisory relationships in general practitioner training

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.

The holy grail of clinical supervision

“…where the trainee undertakes placement) and the wider training environment (e.g. regional and national training programmes) because the traditional 1:1 relationship is no longer sufficient given the increasing complexities in health care settings . The findings of this review are supported by a seminal paper by Kilminster and Jolly that emphasised the importance of a positive supervisory relationship and identified several other factors that lead to effective supervision in the medical education context.…”

“…In this issue of Medical Education, Jackson and colleagues present the findings of a systematic review on supervisory relationships in general practice (GP) training . Their results enable them to build on, and further develop, Bordin's working alliance model for postgraduate GP supervision training, which emphasises the explicit sharing of expectations relating to goals, tasks and roles to facilitate negotiation and agreement between parties within the context of clinical supervision.…”

“…This is confounded by the issue of power imbalances inherent in clinical supervision. Jackson and colleagues identified that supervisors aimed to support their trainee's learning needs, but monitoring and assessment in supervision risked reduction of trainees’ openness about their vulnerabilities. They propose that this issue can be ameliorated to an extent by the supervisors facilitating a non‐hierarchical relationship and recognising and respecting their trainees, whereas trainees are encouraged to provide timely and open feedback to supervisors …”

Tensions in postgraduate training: Meaningful engagement or ‘tick‐box’ supervision?

“…1,18 The pursuit of clarity, safety and agreement in supervision may go some way to facilitate meaningful engagement. 20 the tensions pervasive in a complex educational landscape must be articulated and understood by trainees and their supervisors…”

A qualitative exploration of the lived experience of GP trainees failing to progress in training

“…Whilst these reasons relate to performance on the day of assessment, research suggests a number of other factors are associated with failure at assessment. These include: GP trainee demographics (non-UK status, black and ethnic minority background and male gender) [6,7]; issues related to day-to-day practice; training and education (heavy workload, reduced work-life balance, poor trainee-trainer relationship) [8][9][10]; health and well-being (stress, burnout and mental illness) [11,12]; conduct and attitude (motivation, low confidence, poor reflective capacity) [13,14]; and finance [14][15][16].…”