Sliding off or Supervising for real? Supervision of Junior Doctors in Medical Hospital Departments: a Qualitative Study

doi:10.21203/rs.3.rs-3115134/v1

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Sliding off or Supervising for real? Supervision of Junior Doctors in Medical Hospital Departments: a Qualitative Study

https://doi.org/10.21203/rs.3.rs-3115134/v1

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OBJECTIVE

Supervision is an essential part of the postgraduate medical training of junior doctors but can be a challenge in real-life clinical settings. This qualitative study explores factors affecting supervision in medical departments and the attempt to implement of a simple supervision (S-light) method.

METHODS

This qualitative study used a constructivist grounded theory approach. Data was collected at four different medical departments in Danish hospitals, where the “S-light” method was introduced. We enrolled eight junior doctors and eight senior doctors. Informants were interviewed about how they act in a supervised situation, what they believed to be both difficult and successful in supervision, and about their use of the “S-light” method.

RESULTS

We found four essential factors affecting supervision: 1) an organization structured pro supervision; 2) a culture of supervision; 3) the individual’s stress resilience and 4) the individual’s idealistic mindset. None of the informants had implement the s-light method. We found that lack of the four resources very often lead to a social pattern we named ‘sliding’, describing doctors' evasion of potential supervisory events.

CONCLUSION

We suggest a conceptual framework towards understanding supervision involving four factors important to maintaining healthy supervision and we describe the social pattern ‘sliding’ away from supervision. Strong implementation procedures seem necessary to implement new supervision methods.

Supervision

junior doctors

medical training

qualitative research

Workbased assesments (WBA) are commonplace in post gradual medical training, but widespread negativity against their use prevail among Junior Doctors (JD’s) as well as Senior Doctors (SD’s) (Massie and Ali, 2016). WBA’s may be based on written feedback (multisource feedback: MSF) (Massie and Ali, 2016; Holm et al, 2021) or on direct observation and oral feedback (Pelgrim et al, 2012). However, both have their problems: Even though MSF is obligatory in the post gradual curriculum in many settings, one study found that written MSF very rarely give the JD suggestions for improvement (Holm et al, 2021). Direct observation, as the foundation for oral feedback also has its limitations, as it has been found to seldom take place and often to be viewed at with negative emotions (Pelgrim et al, 2012).

Junior doctor supervision is essential to train competent doctors. However, the act of supervision itself does not necessarily lead to effective learning. Cottrell et al (2002) argues that the quality of the supervisory relationship is key to effective supervision. The supervision relationship is complex and influenced by both cultural and historical ways of acting and being as both a JD and a SD. Launer and Hogarth (2011) argues that good supervision constitutes both ’availability and presence’, ’candour and respect’ as well as ’reflection and complexity’. This is not necessarily common in all clinical setups.

These difficulties may be prevalent particularly in Danish medical bed wards, where transferals and ward rounds are mainly done by JD’s and SD’s working on their own, rather than in acute admission departments, where the JD more commonly work under the routine supervision of senior colleagues. We also felt that here in Denmark, a main obstacle to supervision might be that supervision is often conceptualized as a formal procedure of structured clinical observation. We therefore wished to implement a simple way of carrying out more informal supervision as way to ensure daily training of JD’s, and to explore barriers and facilitators of supervision in general and possibly identify basic social processes regarding supervision.

The use of the word ‘supervision’ may cover a spectrum of practices. On one end of the spectrum is the classic bed-side structured clinical supervision, where a JD works uninterrupted under full observation from the more experienced colleague, who can then later give his assessment and/or feedback. On the other end of the spectrum are more informal exchanges of ideas between a JD and a SD, e.g., in the form of feedback, conferring with a senior colleague, or simply asking a colleague for help. For this project, we defined supervision in a broad sense, encompassing all patient interactions done by a JD and a SD together, where a patient or the file notes were reviewed with the main purpose of learning for the junior doctor.

While previous studies and surveys primarily investigated the methods, extent, motivation, and assessment of supervision, we want to explore which factors affect whether supervision takes place or not. This study therefore had three main objectives:

To implement a ‘lighter’ model of supervision

To explore factors related to supervision challenges

To identify basic social processes in supervision

We wished to remain open to discover the main issues regarding supervision in this setting, rather than to test preconceived ideas and theories. Thus, we adopted at Grounded Theory approach (Charmaz, 1990; Morse et al, 2009; Glaser and Strauss, 1967). Our findings were then subsequently related to relevant literature.

Qualitative Research informed by Grounded Theory

Our qualitative methods were inspired by Grounded Theory (GT), mainly Kathy Charmaz’ (1990) constructivist GT and qualitative research methods (Charmaz, 1990; Morse et al, 2009). We have used a four-step coding process to analyze interviews and memos and have in this regard been inspired from the work of grounded theorists Glaser and Strauss (1967). The sampling process and analysis is described below and summarized in Table 1.

Setting and Informants

We initially contacted 17 medical departments in the Danish region Zealand by e-mail inviting them to the study. To be included there had to be daily ward rounds at the department. Three department leaders never responded to our repeated requests for participation, three did not have daily rounds, and seven declined due to various reasons - mainly time constraints. In the end, four medical departments were included, including various specialties.

All four medical departments were regarded as interested in enhancing the medical education of junior doctors and supervision by their administration. At all four medical departments, junior and senior doctors performed ward rounds as teams that may alter from day to day. The team members worked independently during every day, but the team gathered for a mid-day conference, where difficult cases were discussed. Junior doctors had the opportunity to ask for both advice and supervision during the rounds, but no stringent structure for this was normally provided.

The inclusion criteria for informants were that both JD’s and SD’s should be employed at the same department of internal medicine. Informants were recruited by oral agreements and by e-mail. In total, 8 junior doctors and 8 senior doctors were interviewed.

A systematic method for quick and easy supervision called ‘the S-light method’ has been developed (Barfod et al, 2018) and was introduced to the departments. The idea behind the method is that supervision should be implemented with at least one patient per junior doctor each day. The JD should complete his or her work with the patient and write the plan in the patients’ file. Subsequently, the SD and the JD should review the notes, and should also re-examine and talk to the patient together afterwards. This contrasts with a more thorough structured clinical supervision, where the senior doctor passively observes the work of the junior doctor during the first contact with the patient. It is also in contrast to ‘confer’, where the JD simply consults the SD for advice.

The ‘S-light method’ was introduced to participating wards through repeated morning lectures and discussions in the wards, and through dissemination of handouts. No training sessions were involved.

Interviews

The informants were interviewed about their experiences with the ‘S-light model’ and their thoughts and experiences with supervision in general. Data collection took place in a 10-month period in 2018–2019. We used a semi-structured interview guide. All interviews were recorded with the memo feature on iPhone after consent. Every interview was fully transcribed in verbatim by the authors.

Ethics

Informants were informed that participation was voluntary and could at any time be withdrawn. Departments and informants are here anonymized. All audio files were deleted after transcription. Ethics committee review stated that no ethical review of the study was needed.

Sampling Sequence and Analysis

We coded all interviews word-by-word and sentence-by-sentence data by asking ourselves the question ‘what happens here?’ and conceptualizing the answer (Glaser and Strauss, 1967).

As shown in Table 1, our analysis was divided in three stages of data sampling and four stages of coding. The coding processes with open coding in the beginning and theoretical coding in the end was also a circular process, where the early methods were re-used during the entire process.

The main objective was to reveal as many of the challenges and benefits regarding supervision as possible from the data, and to understand the social processes around supervision.

The codes were selected and developed to form the basis of our theory. The theory was deduced through comparison and re-categorization of codes.

We wrote memos during each process, i.e., after each interview and after internal discussions and research meetings, and after presentations of preliminary results to colleagues (Glaser and Strauss, 1967). These memos were also regarded as data.

The views of JD’s and SD’s did supplement each other well, and a common picture emerged. Four factors were found to be essential for an informant’s tendency to take part in a supervision relation, or to do the opposite - slide away from supervision: 1) an organization structured pro supervision, 2) a culture of supervision, 3) the individual’s stress resilience and 4) the individual’s idealistic mindset (Table 2).

In general, supervision was mainly talked about as something that was lacking. We were unable to find any informants, who had adopted the S-light model, although supervision in other forms might occasionally occur. We identified an often-occurring phenomenon: ‘Sliding’ away from supervision.

Sliding occurred when the four factors were not sufficiently present. The two individual characteristics seemed to determine three different ways of sliding away from supervision: Happy sliding, quiet sliding and regretful sliding (Table 2). These sliding behaviors and the individual characteristics were similar in JD’s and SD’s.

The results are summarized in Table 2 and described in more detail below.

1) An ´Organization Structured pro Supervision´

Several informants mentioned the structure of the department organization, work planning and practical organization in the department as important factors to supervision. Many mentioned the overall approach to supervision at the level of management, e.g., the policy and framework set by management. We found five subcategories:

Time constraints were often mentioned as a reason why supervision may not happen. A SD said:

“This just takes time. So now, for instance this JD, where it was intended that my colleague should have supervised today. And it is given that I can just sweep in and do someone else's work. And in order to do so requires that my schedule is not too busy”.

Goals of the department points towards the importance of the supervision standards set by the management. When informants felt that the department leader stressed the importance of supervision, it seemed more likely to happen.

Structure of supervision plans highlights the way supervision is planned in the specific department e.g., in the form of ad hoc supervision or systematic supervision. Systematic supervision was called for by several informants.

Surroundings when supervising was also a code in data and it relates to the physical conditions mentioned as crucial to supervision, including peace and quiet.

Organization in teams depicts the importance of planning for teamwork. A SD explained:

”Well there is no doubt that if you had some teams you worked in, so that you knew that you belonged to a team, and that team always had rounds together or was able to work together, then you would also be a little more interested in teaching a colleague in being really good at the functions that now needs to be filled”.

2) ´A Culture of Supervision´

A workplace culture can be understood as the common values, stories and behavioral patterns at a department (Watling, 2020). In our theory, a culture of supervision emerged as a main factor, containing four subcategories:

A pattern of culture is our term for the informant’s feelings, understandings and thoughts about cooperation, interaction and communication between colleagues at the department when it comes to the supervisory relationship. It characterizes a resource in the department where it is natural to ask a colleague for help and knowledge, where it is natural to ‘look each other over the shoulder’ and to both give and receive constructive criticism. Several informants described how these cultural aspects could either facilitate or inhibit their desire to enter a supervision relation.

A cultural change was described by several informants as a necessity. A JD says:

“… if one could get such an atmosphere in his department that 'we are the eldest, we are the wisest and the JDs can for obvious reasons not know as much as we can - therefore we must be open to and accepting of that’. I think that could be a really nice place to be”.

A comfortable atmosphere describes a desire for a working environment that allows mistakes – and learning from them.

Team spirit was identified as an important factor in supervision, where colleagues wish to help each other.

3) The Individual’s `Stress Resilience´

“Stress resilience” describes how an individual has the ability to overcome the stress of entering a supervisory relation. This trait seemed closely related to the individual’s stress tolerance in general. We found four subcategories relating to “stress resilience”:

Energy requirement describes that for both JDs and SDs, energy is needed when performing genuine supervision. Many doctors simply felt too stressed or almost burned out to prioritize learning. And the experience of the amount of energy required for supervision varies a lot from person to person.

Variation of resilience is a subcategory depicting that the stress resilience may also vary in the same person, e.g., because one informant may prefer one colleague to others, or one method of supervision is preferred rather than others. A SD tells:

“The amount of work in supervision for me also depends a bit on the junior doctor and how much they are able to”.

Awkwardness is a code that sprung from the data revealing concerns about both pride and awkwardness. A SD says:

“… so you could also be afraid of ‘stepping on one’s toes’. And I think that that's why doctors are generally not very good at either criticizing or praising very well. I have a hard time doing this myself, I have an incredibly hard time giving bad feedback to anyone. It drains me of energy”.

Fear was expressed by several JDs, when entering a supervisory relation. The fear of rejection and the fear of appearing uncertain towards a colleague were seen as major barriers. One JD talks about asking questions, and how it relates to fear:

“I always ask for help when I need it, but the feeling in my stomach may be a little different depending on who to ask. Sometimes you simply just get the response instead of saying 'yes let me hear' or they just say 'yes' and don’t look up - then you become like,' yeah, we have to talk about this for a few minutes when you're done’ 'and then they say ‘no no’ and look away while they ask you to just keep talking, while they just sit and work on something else. And of course, you could point out that it's not an admission ticket to supervision, because they work with what they want to do, and then they listen with half an ear, and I don’t really think that's quite okay”.

4) The Individual’s “Idealistic Mindset”

We found it to be of great importance for the degree of supervision, whether the informant generally had an “idealistic mindset” or not. This mindset is not just towards supervision but can be seen as a more basic set of values or a certain pattern of thoughts in relation to the individuals’ role as a doctor and the working conditions he or she is surrounded by. We identified four main subcategories relating to supervision:

Apprenticeship describes the expressed need for SD’s and JD’s to see the patient together, to facilitate learning and patient safety. Apprenticeship here also refers to the relation between SD’s and JD’s as key to supervision. Supervision seemed to occur, when the SD cared about the JD, and when the JD felt comfortable with, and respected the SD.

Resistance towards being a computer doctor is a theme for several doctors, who often complain about the amount of time spent at computers, and the lack of time spent with patients.

Both subcategories are exemplified in the following quote from a SD:

”One must be told that it is okay to ask questions and to interrupt. And then I think there should be a rule that says that when you supervise a colleague, then you should at least see the patient yourself at some point, because otherwise we become “computer doctors”, and that's a shame for us in general, is it not?”

Tolerating “stupid questions” was quickly identified as factor pro supervision amongst doctors with an idealistic mindset.

Mutual will towards supervision. This subcategory describes that many informants discussed the shared responsibility – and often placed much of the responsibility on themselves. For instance, One JD places the responsibility not solely at the SDs but also at the JD’s themselves:

”You can’t expect SDs to come and say ‘hey – shouldn’t I go in with you to the patient’ or something – so basically I just have to be better at taking the lead myself. So, I think that if you want to learn something, then the responsibility lies with the one who has to learn and not with the others”.

Similarly, one SD expresses – after some hesitation – how he as a SD might facilitate an atmosphere where JDs are comfortable about expecting supervision from SDs:

”And I could help bring a little spirit to it and share the idea that the younger doctors have some expectations of us – especially also in regard to supervision. But I don’t really think it will happen just like that. I want to be able to do it because I think it’s so important”.

Lack of Supervision and Sliding

An ideal environment for supervision is thus found when the four factors – or resources - are present: 1) an organization structured pro supervision 2) a culture of supervision 3) the individual’s stress resilience as well as 4) the individual’s idealistic mindset.

When the four resources are not sufficiently present, we experienced ‘sliding’.

We were unable to find any informants, who had implemented the S-light model, and in general, in the majority of situations, where supervision might have occurred, it did not happen. When we confronted the doctors, many doctors expressed, how this was unfortunate, and that more supervision would have been an advantage. They rarely stated it was not possible, but rather that it just did not happen in the specific situation. We felt, that doctors “dodged” the opportunity either consciously or unconsciously – they ’slided‘ away.

Sliding can occur in both JDs and SDs. Sliding does not necessarily take place as a deliberate act but arises in the interaction between doctors in the tense field between the individual’s inner truth and their actual behavior in a specific setting.

Quite often, several of the above-mentioned factors and subcategories interacted to create sliding, e.g., the subcategories fear (fear of appearing uncertain) as well as awkwardness combined with lack of time (high workload) in the department.

A SD talks about lack of time as a reason for sliding away:

”So, there is also the fact that sometimes it is faster just to do the exam yourself. Therefore, you will be able to go home faster yourself than if you had to put the JD to work, and then go in afterwards and make the changes that are needed and explain why to the JD. There is also an element of convenience in it when it is so much easier to deal with the patient yourself and to make some decisions run smoother – although the JD does not get to learn from it”.

Lack of an organizational structure pro supervision can also contribute to sliding in interaction with other subcategories, e.g., in the form of lack of organization in teams, because lack of personal relations let to awkwardness and fear instead of tolerating stupid questions.

The energy requirement for a SD for supervision may potentially lead to sliding when combined with a feeling of awkwardness. Sliding occurs for SDs when external interruptions in their clinical work occur too often, e.g., in the form of inquiries from JD’s. In addition, an experience of awkwardness in the supervision relationship, including the need to provide constructive criticism for the JD’s, can lead to sliding away from supervision.

Sliding in three ways determined by Individual Factors

In a given context, i.e., in a specific situation with an organizational structure and culture, we found that JD’s as well as SD’s might slide away from supervision in three different ways according to their individual characteristics. The main characteristics of individuals in this regard were ’stress resilience‘ and ’idealistic mindset‘. The main ways of sliding were ’happy sliding‘, ’regretful sliding‘ and ’quiet sliding‘. Please see Fig. 1 and details below.

’Happy sliding‘ was observed when the doctor was stress resilient but did not have a very idealistic mindset towards supervision. He or she would then express a behavior of dodging away without regrets.

’Regretful sliding‘ was observed when the doctor had an idealistic mindset towards supervision but was sensitive to the stress of supervision. For example, an idealistic JD felt supervision could lead to a risk of revealing his or her own inexperience in front of a senior colleague, felt fear and thus became less stress resilient:

”Everyone knows that in the group of SDs, they talk about 'those younger doctors who can’t make any decisions, they have to ask about everything' and such - it's just a bad atmosphere - yeah it gives such a bad mood, I think. Even if they say it straight to your face - I do not know if it is better or worse - but then again it is just the fact that they go around and have these thoughts about you - so I think myself that the youngest doctors who come out now straight from university for example, they know very well that when they have not been out in the clinic, they have to ask about everything in the clinic, so it is dangerous if they do not. Well, but I think they have some - the elderly, they have completely forgotten, and I think that is too inappropriate.”

’Quiet sliding‘ was observed when doctors neither had the stress resilience or the idealistic mindset necessary for supervision. Doctors in these situations were often less verbalized and seemed generally to be less involved in the social and organizational aspects of the ward. “Quiet sliding” seemed associated with a focus on ’surviving‘ as a clinical doctor in general.

We found supervision to be very rare in clinical practice. There were four main factors influencing its occurrence: 1) organization 2) culture 3) individual stress resilience and 4) individual idealistic mindset. Most often, doctors ‘slided’ away from supervision, either as happy sliding, regretful sliding or quiet sliding. Our suggested ‘S-light’ method of supervision was not successfully implemented.

The three ways of sliding determined by the two individual factors are in our understanding new concepts in the literature on supervision, although e.g., engagement (Barrett et al, 2017) has been identified before.

The lack of efficiency of the S-light method might be attributable to the lack of the four determining factors in our sample but may also have to do with a deficiency in our persuasion or teaching skills. For example, the method was only presented during lectures, and no training sessions were arranged.

The workload and the structure of the organization was very often described as inhibitory to supervision. Workload has been previously identified as major barrier to supervision (Andreassen and Malling, 2019), although not by all researchers (Celebi et al, 2012). To increase supervision, reducing the workload alone might not be sufficient, and might not always be possible. Similarly, a culture of supervision may not in itself be sufficient to increase the occurrence of supervision in a department.

The strengths of this study are the exploratory nature of the GT method, and our rigorous and meticulous transcription and coding, and the triangulation with several researchers. The concepts developed may well be transferred and used to understand and analyze other settings, although the descriptive aspects of the findings may not be generalizable. A study on theory-based interview studies (Francis et al, 2009) designates saturation as achieved by a minimum of 10 interviews and up to three interviews analyzed without new codes have emerged. Our study fulfills these criteria for saturation.

This study also has weaknesses. Qualitative methods can in general be criticized for their lack of reproducibility and of not being able to provide evidence-based results. The medical wards in Denmark may have two elements that make supervision even less likely to happen than in many other countries. First, a 37-hour workweek and high clinical standards and a good salary all contributes to a very high demand for every doctor to focus on doing a lot of clinical work fast. Second, the country is known for its flat hierarchy and its ’Law of Jante‘ meaning than no one should stand out as superior to others (Wikipedia), an attitude that may perhaps be a barrier for supervision. Thus, the concepts and our theory may be less useful in settings, where the working hours are longer and the hierarchy less flat.

The results of this study may be used in practice. The conceptual model of the four factors important for supervision as well as the concept of sliding can be seen as tangible tools in identifying factors in the department that may help the department work against sliding. The conceptual model in itself cannot create a culture of supervision or an organization structure pro supervision, nor the individual resources for an idealistic mindset or the stress resilience of the individual doctor. But potentially it can relieve some of the inhibitory factors of supervision by drawing attention to them. For example, happy sliding may be counteracted by informing doctors in a department of the great learning potential in supervision, and regretful sliding may be counteracted in teaching brief supervision methodologies like ’S-light’ (Barfod et al, 2018).

Further research is needed. For example, we need to study how the structural level interact with the other factors of supervision e.g., how management and production in a hospital influences on the doctor’s tendency to be involved in supervision. For instance, the effects of establishing steady teams that repeatedly do rounds together might be studied. “Workplace culture” needs further research (Watling, 2020). We find that further studies of how workplace culture of supervision can be influenced is necessary, as well as research into the individual’s training, motivation and resources for supervision.

In conclusion, we present a conceptual framework for understanding the supervision of doctors in clinical practice. Strong training efforts might be needed to implement new supervision routines like the S-light method. To facilitate supervision in general, we suggest that efforts must be made on both a structural, a cultural and the individual level. We suggest that stress resilience and idealistic mindsets of the individual must be facilitated, and that awareness of the danger of sliding away from supervision is essential.

Interests and funding

The authors have no financial or proprietary interests in any material discussed in this article.

The authors did not receive support from any organization for the submitted work.

Ethics

Ethics committee review stated that no ethical review of the study was needed.

Data committee review stated that no data review of the study was needed.

Availability Statement

All data, recordings, transcriptions, data sampling and coding, are archived and anonymized by authors according to The Danish Data Protection Agency. The data generated and analyzed during the current study are not publicly available due to anonymization. The data are available from the corresponding author on reasonable request though restrictions may apply to the availability due to the anonymization of the interviewees.

Acknowledgements

Warm thanks to the agreeing department leaders and the participating informants.

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Table 1 and 2 are available in the Supplementary Files section.

No competing interests reported.

Table1.png
Table 1: The sampling process and analysis of this study
Table2.png
Table 2: Factors and subcategories influencing supervision, and three types of sliding away from supervision among Junior and Senior Doctors at four medical wards in Denmark.

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Sliding off or Supervising for real? Supervision of Junior Doctors in Medical Hospital Departments: a Qualitative Study

Status:

Version 1

Abstract

OBJECTIVE

METHODS

RESULTS

CONCLUSION

Figures

Main Text Introduction

Materials and Methods

Qualitative Research informed by Grounded Theory

Setting and Informants

Interviews

Ethics

Sampling Sequence and Analysis

Results

1) An ´Organization Structured pro Supervision´

2) ´A Culture of Supervision´

3) The Individual’s `Stress Resilience´

4) The Individual’s “Idealistic Mindset”

Sliding in three ways determined by Individual Factors

Discussion

Declarations

Interests and funding

Ethics

Availability Statement

Acknowledgements

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1