1. Characteristics of each of the four educational roles
Thematic analysis of the prevailing descriptions of role modelling, teaching, tutoring, coaching and supervision were carried out. Their characteristics and descriptions are highlighted in the table below (Table 2).
Characteristics and descriptions
|
References
|
Role Modelling
|
Webster’s Dictionary “a person considered as a standard of excellence to be imitated.”
|
[51-53]
|
Combination of personal characteristics (Heart), professional patient care (Hands-on), and teaching that involves continuously making the implicit explicit (Head). Being a role model, as opposed to being a teacher or a mentor when the moment calls for it, implies that the clinical trainer integrates the “3Hs” as a unity all the time and everywhere.
|
[54]
|
everything faculty do in their being and acting as professionals both inside and outside the hospital
|
[55-58]
|
Specific observable behaviour (as well as attitudes and values) to be emulated or even surpassed by residents
|
[58-62]
|
Role modelling has been defined as "a way responses (specific observable behaviour as well as attitudes and values) can be learned or weakened through exposure to significant others".
|
[62]
|
Demonstration of clinical skills, modelling and articulation of expert thought processes and manifestation of positive professional characteristics
|
[63]
|
Interactional, transactional process, which occurs simultaneously with multiple models and changes over time.
|
[64]
|
Teaching and Tutoring
|
Clinical skills training and knowledge transfer
|
[65-71]
|
Professional outcome-based assessment
|
[66, 70, 71]
|
Feedback provided for students after teaching or tutoring
|
[65, 66]
|
Standardized program structure
|
[67, 68]
|
Coaching
|
Individualized
|
[72-81]
|
Safe space for coached to make mistakes and learn
|
[73, 76, 77, 82, 83]
|
Deliberate teaching with focused goals
|
[75, 82, 84-86]
|
Individualized feedback through observation
|
[74-77, 79, 81-91]
|
Repetition
|
[82, 87, 89, 90]
|
Supervision
|
Apprenticeship
|
[92]
|
Clinical care under the oversight of a more senior physician
|
[92]
|
Improve resident education through identifying trainee problems, provision of feedback and supporting trainee
|
[93-98]
|
Ensure effective and safe patient care
|
[92, 93, 99]
|
Table 2: Characteristics of the four educational roles
2. Educational processes
Role modelling is often a ‘one off’ unstructured experience that neither the learner nor the role model has prepared for [100]. Role modelling may be unconsciously carried out and may be either an exemplary action or one that ought not to be repeated [55, 57, 59, 62]. Given the unplanned nature of role modelling, it may even breach standards of practice [55, 57, 59, 62]. Role modelling may not have a longitudinal component and is often not appraised [55, 57, 59, 62], subject to feedback or reflection [60, 63, 100-102].
The learning processes in teaching and tutoring, coaching and supervision are interactive [64-66, 74-77, 79, 81-91, 93-98], context-specific, goal-sensitive and dynamic [63, 75, 82, 84-86, 92] process that are guided by the objectives of the clinical training program [66, 70, 71, 92, 93, 99] and supported and overseen by a host organization [67, 68, 73, 76, 77, 82, 83, 92].
Teaching and tutoring need not be matched though having learners and tutors with complementary abilities, motivations, personalities, and values for coaching and supervision is helpful. Teaching and tutoring, coaching and supervision is influenced by individual learning goals [75, 82, 84-86], relationships [72-81], program structure [67, 68], assessments [66, 70, 71], and environment [64]. All teaching and tutoring, coaching and supervision programs are structured, planned, and often have longitudinal component which are horizontally and vertically integrated. [90, 103, 104] The programs usually include feedback, reflection and an evaluative process [90, 103, 104].
The distinctive aspects of each learning processes are highlighted in Figure 2
3. Nature of Relationship
Role Modelling
Role modelling are unpredictable and involved varying levels of interaction and communication [100]. Some interactions are purposive built through sharing of professional and personal experiences and socializing [60, 63, 101, 102] whilst other are entirely opportunistic.
A lack of structure however may result in negative role modelling [55, 57, 59, 62]. Negative role modelling [55, 57, 59, 62] may dissuade students of career choices [57], cause trainees to become more cynical about academic life [62], discourage reflective practice skills [55] and undermine professional and patient centered behaviour [63].
Teaching and Tutoring
Structured programs [66] that include experiential learning [65-71], discussions [70, 71], and or guided reflections [65, 66] formed the basis for teacher-student interactions [65, 70]. Given the variability of these interactions [68, 69, 71, 105], teacher-student relationships tend to be superficial [65, 66]. However, supportive and approachable teachers [65-67, 106], who are willing to commit and provide student-centric teachings [65, 66, 70, 105], are able to develop more successful learning relationships and achieve greater goals [69, 70, 106].
Coaching
The relationship between the coach and trainee is focused upon learning a specific skill [72]. The complexity of the skill determines the duration of the relationship [72].
Coaching begins with the demonstration of the skills in a planned role modelling process, which tapers over time as goals were achieved and as trainees develop their ability to self-monitor and sustain their training [72].
It is debatable as to whether coaching provides psychological and emotional support [74, 80, 84]. Some commentators suggest that coaching relationships are transactional and focused upon professional improvement whilst others suggest the presence of evaluations within coaching interactions necessitate a trusting [74, 80, 84] and safe environment [73, 90, 91].
Supervision
The supervisory relationships are hierarchical [92]. With the trainee dependent on the supervisor for academic progression and career advancement [92], trusting relationships between supervisor and trainee are less likely [92-99].
A comparison of the nature of relationships across various educational roles are found in Appendix A, Table 4.
4. Problems faced in the four educational roles
Each of these educational approaches face common problems. Many revolve around insufficient training, poor program structure, inadequate learning resources and inaccurate program evaluation and learning assessment [55, 80, 93, 95, 96, 100, 107-111].
Role modelling faces limited time for teaching [55, 100, 107-109] and bedside tutorials [110] whilst coaching faces inadequate financial, administrative and assessment support that are not conducive of nurturing organizational culture to ensure protected time and recognition for coaches [80, 111].
Supervision faces organizational issues that include a lack of consistent level of support and training [93], resource limitation and competing tensions between service and education demands [95, 96]. A detailed account of these challenges is found in Appendix B, Table 5.
Drawing the findings together
Based on the data from the four systematic reviews, it is possible to proffer a clearer understanding of each of the approaches.
i) Role Modelling
Positive role modelling can be defined as “a process where a trainer consciously or unconsciously demonstrates positive or negative behaviours, actions or attitudes. The learner observes, weighs up and reflects upon these characteristics, skills and or behaviours upon their own practice/attitude/behaviour and emulates, experiments, and assimilates it into his/her own personal/professional identity. Positive role modelling is more impactful when it occurs in a trusting, professional relationship.” [51-55, 57-64, 100, 102, 109, 112-115]
ii) Teaching and tutoring
Teaching and tutoring is “a professional goal-specific [66], task-oriented [66], standardized [67, 68], and structured learning process [66, 69] on clinical knowledge and skills [65-71], driven by clinical competency and performance outcomes [69, 70, 106]. The professional [65, 66, 69-71, 105, 106], tutor-, and student-dependent [65, 66] tutor-learner relationship requires protected time [65-67, 70] to develop in a safe and productive learning environment [69], supported by the host organization [67], for effective teaching [65, 67, 69-71, 106] and feedback [66, 67, 70, 71, 105] processes.”
iii) Coaching
Coaching can be defined as a “longitudinal professional relationship between an expert coach and a trainee focused upon mastery of a clearly defined, measurable and achievable skill that is that the trainee or training organization feels the trainee can improve upon. The relationship is built upon professional trust in a ‘safe environment’ that facilitates practice of the skill. The coach evaluates the performance, needs and abilities of the trainee, role models skills, encourages learning, provides specific individualized feedback and devices and adapts a plan to achieve the goals. The trainee is accountable for their training and responsible for self-monitoring.” [73-86, 88-91]
iv) Supervision
Supervision is an “individualized, focused, goal-specific, time-limited and context-sensitive clinical training process by a senior clinician aimed at assessing and improving particular gaps and weaknesses in the clinical care and patient safety by trainees by providing them with oversight, guidance and feedback and holding trainees up and accountable to established clinical standards and codes of practice. This process will utilize coaching and role modelling to meet its goals [92-99].
Comparing the findings of the four systematic reviews, there are a number of key insights and similarities that may be discerned. These commonalities lay the foundation for a collective perspective of the four educational approaches. These features are shown in Table 3 and the characteristics of each approach is shown in Figure 3.
Features
|
Role model
|
Teaching tutoring
|
Coach
|
Supervision
|
Planned
|
No
|
Yes
|
Yes
|
Yes
|
Matching
|
No
|
Equivocal
|
Yes
|
Yes
|
Structure
|
No
|
Yes
|
Yes
|
Yes
|
Positive/Negative Exemplar
|
Both
|
Positive
|
Positive
|
Positive
|
Assessment
|
No
|
Yes
|
Yes
|
Yes
|
Feedback
|
No
|
Maybe
|
Yes
|
Yes
|
Context sensitive
|
No
|
Yes
|
Yes
|
Yes
|
Goal specific
|
No
|
Yes
|
Yes
|
Yes
|
Bilateral/dynamic interaction
|
No
|
Yes
|
Yes
|
Yes
|
Longitudinal
|
No
|
Yes
|
Yes
|
Yes
|
Integrated
|
No
|
Yes
|
Yes
|
Yes
|
Reflection
|
No
|
Yes
|
Yes
|
Yes
|
Type of relation
|
Superficial
|
Superficial
|
Trusting
|
Trusting/deep
|
Tutor dependent
|
Maybe
|
Yes
|
Yes
|
Yes
|
Specific
|
No
|
Yes
|
Yes
|
Yes
|
Practice
|
No
|
Yes
|
Yes
|
Yes
|
Psycho-emotional support
|
No
|
Yes
|
Yes
|
Yes
|
Table 3: Features of the role modelling, teaching and tutoring, coaching and supervision
The data would suggest that the more relevant aspects of role modelling appears to be contained within teaching and tutoring, which in turn appears to be subsumed by coaching. Supervision appears to contain features of role modelling, teaching and tutoring, and coaching.
Viewed figuratively as concentric rings, role modelling would be at the centre of the rings, enclosed by teaching and tutoring, then coaching and finally supervision as the outer most ring.
Stage 2 Mapping mentoring practice
To determine mentoring’s relationship with the concentric rings featured in Figure 3, Stage 2 will provide a summary of prevailing concepts of mentoring drawn from two recent systematic scoping reviews of novice mentoring and a recent study of mentoring experiences within a novice mentoring program.
Sng et al. (2017) [2]’s and Tan et al. (2018) [12]’s systematic scoping reviews highlight a number of key aspects of mentoring
- Mentoring can be defined as ‘dynamic, context dependent, goal sensitive, mutually beneficial relationship between an experienced clinician and junior clinicians and or undergraduates that is focused upon advancing the development of the mentee’.
- Mentoring possesses adopt an evolving, adaptive, goal-specific, context-sensitive, and mentee-, mentor-, relationship-, and host organization-dependent nature (mentoring’s nature) that prevents conflation with other forms of mentoring.
- Novice mentoring’s success lies with its nurturing of personalized relationships between the mentee and mentor
- To develop personalized mentoring relationships, there must be balance between individualization of mentoring relationships that includes catering to the mentee’s needs, abilities, goals and situation and ensuring a consistent mentoring approach that is both compliant to prevailing codes of conduct and sufficiently structured to allow effective, timely, appropriate, personalized, specific, holistic, longitudinal and accessible evaluations and support for mentees, mentoring and the mentoring relationship.
Evidencing these findings and forwarding new insights of novice mentoring, Krishna et al. (2019) [3]’s study of mentoring experiences in a novice mentoring program also unearthed new aspects to mentoring. These include
- mentoring’s competency-based stages of development that requires mentees to achieve basic competencies at each stage of the mentoring process before progressing to the next stage.
- progress through the various stages of mentoring requires effective communication, timely and appropriate assessments and support appropriate balancing between consistency and structure.
- oversight and support of the mentoring process depends upon the host organization and well trained and supported mentors.
Stage 3 Mentoring Spectrum
Mentoring’s use of personalized holistic and longitudinal support throughout the mentoring process would require mentees to be taught, and provided with guidance as they apply their knowledge and skills, be assessed and provided with feedback and then re-evaluated before progressing to the next stage of the mentoring process. At each stage of the mentoring process which Krishna et al. (2019) [3] describe as “ ‘circumscribed sequential projects’ with ‘specific goals and competency requirements’ ”, it is likely that mentors will employ role modelling, teaching and tutoring, coaching and supervision to support the mentee and the evolving mentoring relationship. This would see mentoring encompassing supervision’s role and occupying the outer most ring in Figure 4.z
This suggests that role modelling, teaching, tutoring, coaching and supervision lie within a mentoring spectrum (Figure 4). The mentoring spectrum describes a range of educational practices contained under the aegis of mentoring beginning with role modelling on the left side of the spectrum and mentoring on the right. Beginning with role modelling, there is progressively complex interactions culminating with personalized attention in role modelling behaviours, attitudes and practices, teaching new skills and knowledge, coaching individual learner’s on different aspects of the skills they need, appraising their progress and providing feedback as they are supervised to complete their immediate goals within the project. Separating supervision from the more complex relationships seen in mentoring is the provision of personalized, timely, holistic and longitudinal support and the adaptation of the mentoring approach to accommodate the mentee’s needs, goals, circumstance and abilities.
Other features that evidence the notion of a mentoring spectrum include
- Motivation of learners
All educational approaches are reliant upon the learner’s ability to observe, discern gaps in their ability, learn, reflect, weigh up considerations, be open to feedback and be accountable for their own learning. However, the approaches rely on increasing learner motivation moving from left to right of the mentoring spectrum.
- Learning Relationship
Moving from left to right along the mentoring spectrum also highlights increasing planning and structuring of the mentoring process. Improved structuring of educational interactions better supports learning relationships and nurtures more holistic and personalised educational relationships. Better learning relationships also facilitate better outcomes.
Learning relationships also become more interactive moving from left to right in the mentoring spectrum. In role modelling, learners may not have an educational relationship with the tutor whilst learning relationships in mentoring are dynamic and enduring [2, 92, 116-119].
- Nurturing learning environment
Building a learning relationship relies on the learning environment and moving from left to right of the mentoring spectrum sees learning environments becoming increasingly important to the quality and nature of the learning relationship. These learning environments also become more individualised and serve to nurture particular learning relationships within the larger educational environment. This is especially evident in supervision and mentoring [90, 91].
- Learning assessment
Assessments also play an increasing role moving from left to right of the mentoring spectrum. These assessments must be timely, appropriate and personalised and accompanied by open and frank discussions and personalized, appropriate, specific, timely, holistic, accessible and longitudinal feedback and support [2, 116-119]. The presence of regular appraisals also reiterate the importance of individualized and safe educational environment [90, 91].
The impact of the mentoring spectrum
An overarching mentoring spectrum combining role modelling, teaching and tutoring, coaching, supervision, and mentoring has wide ramification upon how these educational approaches are employed.
- The implication upon mentor training is significant. Acknowledging the roles to be played within the mentoring spectrum highlights the need for mentors to be trained in all these educational approaches.
- The unplanned and unconscious nature of role modelling and the need for balance between personalising and consistency within the mentoring approach both highlight the need for clear standards of practice, codes of conduct and practice guidelines (henceforth Codes of Practice or CoP). There must also be opportunities for mentee and mentors to align expectations and accept their responsibilities and roles and for mentees and mentors to be briefed on the prevailing goals and timelines of their respective educational projects and processes.
- The learners and tutors must also be appropriately matched to ensure that they have complementary working styles, learning approaches and personalities, goals and abilities [120, 121]. This will help build better educational interactions.
The implications of the mentoring spectrum upon mentoring practice is vast and includes requiring
- mentors-in-training to be trained and skilled on all these educational approaches and be mentored when applying these skillsets and competencies for each of the educational roles.
- mentors and mentees to be briefed on CoPs, expectations on roles, responsibilities and expectations and effective oversight, assessment, and support provided by the host organization.
- robust, longitudinal and holistic assessment processes in light of the changing nature of the mentoring process and the mentor’s roles and the presence of evolving mentoring relationships and different stages of the various aspects within the mentoring spectrum.
- the host organization to take an active role in overseeing and providing personalized, appropriate, specific, timely, holistic, accessible and longitudinal financial and administrative support in running and overseeing the mentoring process given the diverse processes within the mentoring spectrum [2, 116-119].
- that the mentoring process is sufficiently structured to accommodate for the inevitable changes in the mentoring process without breaching the CoP.
- the need for a safe and nurturing working environment that will nurture trusting and enduring mentoring relationships that will not only enhance better role modelling when the mentee has established ties with the mentor but also facilitate discussions that extend beyond professional issues which will allow the provision of holistic support.
- the need for an open and safe mentoring culture that allows open discussions, constructive feedback and frank discussions.
Limitation
This review posits that these practices are interrelated is based on a number of novel yet unproven assumptions. Selecting only four of the many educational roles also limits the scope of understanding of the entire spectrum of educational roles in mentoring. In addition, the practices described in this review focus specific education settings, and draw from a particular definition of role modelling, teaching and tutoring supervision and coaching that may not be applicable in other education settings. Within the context of role modelling for example, there is no consideration of negative role modelling which limits the validity of the conclusions reached. In addition, many of the papers contextualized within the European and American healthcare system and training programs, limit their applicability to other educational and healthcare systems.