Supervision

Supervision and Patient Safety

Quality supervision is essential for learning, competent delivery of care and patient safety. MDA National's Education Services team review what constitutes effective supervision and propose suggestions for enhancement.
The supervisor's immediate responsibility for patient safety has a central role in vocational training, particularly in helping the supervised doctor learn personal accountability for quality of care. Patient safety can be enhanced through a positive supervisory relationship that encourages the supervised doctor to approach their supervisor for support. Supervised doctors may not ask for help for various reasons including fear of recrimination, embarrassment at demonstrating a lack of competence, or fear regarding a loss of trust, autonomy or respect.

Supervision is an important part of medical education, allowing experiences to be processed through guided learning. Effective supervision develops medical professionalism and attainment of skills for the supervised doctor thus producing better health outcomes and safe care for patients.

Roles and responsibilities

Effective supervisory relationships are grounded in a mutual understanding of the responsibilities of a supervisor and supervised doctor, and these responsibilities need to be explicitly identified by both parties at the start of supervision. One area for discussion is the medico-legal issues associated with each role. It is a requirement that the supervised doctor does not perform any duties outside of the medical indemnity insurance scope of their supervisor. It is also important that the supervised doctor knows what to do if the supervisor is unavailable and assistance is required and when to refer patients to their supervisor for review.

Supervisors' responsibilities

1. Communicating responsibilities at the initial supervision stage:

• Explain how the supervision will be conducted in line with the requirements of the medical college and training provider/organisation.
• Establish guidelines and triggers where the supervised doctor must seek advice.
• Establish a feedback system to support the supervised doctor's self-regulation.
• Explain arrangements if the supervisor is sick or unable to be contacted.
• Explain medico-legal insurance and its impact on scope of practice.
• Review where common mistakes in the workplace occur and develop strategies to minimise risk.
• Establish an approachable and supportive demeanor.
• Provide an orientation to the people, policies and systems of the workplace.

2. Supervisors' responsibilities during supervision:

• Establish the supervised doctor's skills, abilities and learning needs, and assist them in developing a learning plan.
• Ensure clinical skills are taught.
• Offer feedback and promote communication, including a review of the feedback system established at the start of the supervision stage.
• Identify and address the supervised doctor's blind spots (see below).
• Handle errors with a "no blame" approach, exploring contributing factors and discussing how to prevent a similar problem in the future.
• Support work-life balance and monitor the supervised doctor's stress levels.
• Tailor supervision style to the individual needs of the supervised doctor.
• Recognise and manage conflict and other problems early.

Responsibilities of the supervised doctor include:

• Establishing what to do if your supervisor is busy and you need assistance.
• Confirming the triggers and rules for when you need to contact your supervisor.
• Preparing adequately for task duties.
• Seeking assistance and advice early if you are unsure of patient treatment.
• Avoiding situations which may risk the safety of the patient, practice or treating doctors.
• Reflecting on experiences to acquire meaningful knowledge, skills and attributes.
• Recording self-reflection notes which prompt questions and establishing times to discuss these.
• Building a communication channel which supports being able to raise concerns and discuss issues with your supervisor.
• Seeking training opportunities and assistance on procedures and systems from a range of staff members where possible.
• Identifying learning gaps and possible training solutions.
• Finding, observing and working with mentors who have high professional standards.
• Being open to challenges.
• Responding to feedback from the supervisor in a structured and professional manner.

The supervised doctor must accept responsibility for clinical decisions they make; however, they should always remember that they are part of a "shared responsibility" with the supervisor and other medical staff. Patient safety must always be the priority.

Blind spots

All doctors have areas in which skills or knowledge is lacking. Supervised doctors who are unaware of their incompetence are unlikely to ask for help and may therefore compromise patient safety. The aim of identifying supervised doctors' blind spots is to ensure that they seek support about patient management from their supervisor when it is required. Supervisors' blind spots in relation to teaching should be investigated to check that they are supervising in a manner that does not risk patient safety.

Strategies for senior doctors to identify their own weaknesses regarding supervision include:

• Arranging supervision support with a mentor.
• Seeking feedback from the supervised doctor.
• Participating in supervision training.

Supervisors can also develop strategies to assist in identifying the blind spots of the doctor they are supervising. These include:

• Selecting random patients to review and discuss diagnosis and management with the supervised doctor.
• Organising occasional sit-in sessions or other observational techniques.
• Requesting the supervised doctor to record daily self-reflection notes where possible to prompt discussion and evaluation of decisions.
• Providing regular feedback including feedback that supports self-regulation.

Self-regulation and feedback

Self-regulation is the ability to evaluate your skills and recognise when to seek support. It is recommended that a feedback system be designed and agreed upon at the start of the supervisory relationship to improve the doctor's self-regulation. The purpose is to improve the supervised doctor's ability to know when to make decisions on their own and when to seek the supervisor's advice. This should be in conjunction with established criteria of when to contact the supervisor.

Feedback principles to improve a supervised doctor's self-regulation:

• Develop self-assessment tasks which are completed and discussed together between the supervisor and supervised doctor.
• Offer timely feedback which not only covers strengths and weaknesses but is corrective, ie commenting on specific and observed behaviours, rather than on general performance, at the time of the event or shortly afterwards.
• Encourage dialogue. Reflection and discussion highlight learning gaps and reinforce understandings.
• Encourage a positive feedback environment focusing on improving learning and patient safety.
• Provide opportunities for the supervised doctor to re-complete tasks they need to improve on after feedback has been given.
• Allow the supervised doctor to explain how feedback could be presented more effectively to suit them.

For a summary of the feedback principles promoting self-regulation visit xxxx

Conclusion

It is critical for patient safety that the supervisor and supervised doctor understand and explicitly define their role and responsibilities at the start of the supervisory relationship. During the supervision period it is vital that blind spots are identified and minimised, and feedback is provided that encourages self-regulation. Patients deserve the most experienced care possible, which means that experienced doctors are required to be available to both the patients and the doctors they are supervising.

It is MDA National's position that, to enhance patient safety, patients should be informed if they are to be treated by a supervised doctor. More safeguards will likely be in place for both the patient and the doctors if the patient is aware that their doctor is being supervised.

A Medical Educator's Perspective

Sadly as time has gone on and with a deepening involvement in medical education, my involvement in clinical practice has reduced and my direct involvement in supervising trainees has also diminished. What has not changed is my belief that clinical supervision is integral in developing the skills and expertise of our junior colleagues. Clinician supervisors commit their time and expertise into mentoring, teaching, coaching and assessing their junior colleagues whilst keeping patients safe, supported and in receipt of high quality care. We need to ensure that our supervisors are trained, supported and acknowledged for the role they play in developing and maintaining a skilled clinical workforce.
I have considered myself privileged to have had the opportunity to be involved in the supervision of junior doctors. It has taught me to be a better doctor. In turn I have focused on maintaining the integrity of clinical supervision in my work in medical education.

I have also had the privilege of working alongside colleagues who are now lifelong friends. Our friendships were forged as part of the supervisor-trainee relationship and I have watched these trainees go on to become exemplary clinicians, and GP supervisors themselves.

The most important element of supervision is the quality of the relationship between supervisor and trainee. Like any relationship, it requires effective communication, trust and mutual respect. It requires an understanding and acceptance of what each other brings to the relationship, including prior experiences and expectations of the supervision process. Like any relationship, there may, at times, be misunderstandings, differences of opinion and in the worst instance, communication breakdown. However provided there is trust, honesty and respect for the importance of the supervisory relationship, the integrity of supervision will remain intact.
There are multiple elements of supervision. Skills such as teaching, assessing, mentoring, coaching, evaluating and providing feedback are all integral to effective supervision. This requires supervisor training and ongoing maintenance of clinical as well as supervising skills.

Supervision is not the responsibility of only one person within the supervision relationship. The trainee is also accountable for ensuring effective supervision is taking place. Patients themselves often play an important role in the provision of feedback about the care that is being provided and in turn the quality of the supervision. Depending on the clinical setting, context and type of clinical training there are often multiple members of the team contributing to the supervision. Clinical supervision is multifaceted in nature and the roles and responsibilities of all parties involved in the supervision need to be acknowledged.

Why is clinical supervision so important? Because it ensures that patients can receive safe and quality care whilst the new clinician is learning their craft, and the novice clinician can receive safe and quality training whilst delivering patient care.

There will always be increased demands on clinicians to see more patients, deliver more clinical services and at the same time teach more students and supervise increasing numbers of trainees. At times the delivery of teaching services will seem to be a competing priority with the delivery of clinical services but in fact the two should be seen as synergistic. Supervising trainees is directly related to being a clinician and should always remain fixed in the heart of the clinical setting. There will always be the need for someone experienced and trained to be available to the trainee to provide clinical assistance, to debrief over clinical cases, to mentor and teach the learner. Exposure to experienced clinicians is essential for trainees to learn how to become experienced clinicians themselves. A positive supervision experience will encourage these trainees to become supervisors themselves for the next generation of clinicians.

Dr Kaye Atkinson is a GP, medical educator and MDA National Member.

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