Nurse Education Today 34 (2014) 783–788
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Review
Supervisors' experiences of workplace supervision of nursing and paramedic students in rural settings: A scoping review Franziska Trede a,⁎, Celina McEwen a,1, Amanda Kenny b,2, Peter O'Meara b,3 a b
The Education For Practice Institute, Charles Sturt University, Locked Bag 450, Silverwater, NSW 2128, Australia La Trobe Rural Health School, Faculty of Health Sciences, La Trobe University Health Sciences, Bendigo, VIC 3550, Australia
a r t i c l e
i n f o
Article history: Accepted 7 October 2013
Keywords: Supervision Supervisor Rural Nursing Paramedicine
s u m m a r y Objectives: We present our findings from a scoping review that sought to identify what is known about nursing and paramedic clinical supervisors' experiences of their supervision practices in rural settings. Our interest in these two groups is based on the central role that nurses and paramedics play in rural health care. Design: Scoping reviews support identification of a broad range of literature, including all types of study designs. We adopted Arksey and O'Malley's five-stage approach: identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarising and reporting results. Data Sources: Databases searched included Academic Search Complete, Springer, Factiva, ProQuest, Ebsco, Informit, VOCEDplus and Scopus. Review Method: Based on our research question and inclusion and exclusion criteria we selected relevant literature and summarised and reported it using Arksey and O'Malley's framework. Results: The review yielded five articles from four countries: Sweden, Belgium, Malaysia and Australia. Conclusion: From this scoping review, we identified key themes related to supervisors' experiences, including clarification of expectations, support from managers and colleagues, the need for shared understanding between university, students and supervisors and required skills and competence in supervising students. © 2013 Elsevier Ltd. All rights reserved.
Introduction In this article, we present our findings from a scoping review of the literature on supervisors' perspectives of their experiences in supervising nursing and paramedic students undertaking rural placements. Understanding supervisors' perspectives can help identify issues associated with student supervision and develop understanding of the enablers that support quality supervision practices. Many different definitions, roles and understandings are used for the term supervisor such as mentor, preceptor and educator (Billay and Yonge, 2004; McCarthy and Murphy, 2010). For the purpose of our review, we defined supervisors as health care professionals employed within a health care agency who mentor, monitor, teach, provide feedback and assess undergraduate students. In our review, the key focus was on supervisors of nursing and paramedic students. Our focus on rural, which we define as nonmetropolitan, was triggered by findings from a study by Siggins Miller Consultants (2012) that identified that workforce maldistribution,
⁎ Corresponding author. Tel./fax: +61 2 9752 9003. E-mail addresses: [email protected] (F. Trede), [email protected] (C. McEwen), [email protected] (A. Kenny), [email protected] (P. O'Meara). 1 Tel.: +61 2 9752 9013; fax: +61 2 9746 3647. 2 Tel.: +61 3 5444 7545. 3 Tel.: +61 3 5444 7870. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.10.003
under-resourcing, geographical isolation and poor access to the internet (characteristics of clinical rural settings) have a major impact on quality student supervision. The focus on nursing and paramedicine was fuelled by the central role that these two groups play in ensuring sustainable health service delivery in rural areas (Duckett and Kenny, 2000; Kenny and Duckett, 2003; Mulholland, 2010). In a study by Mulholland (2010), a dearth of literature relating to rural paramedic education was identified. In the rural nursing literature, Kenny and Duckett (2003) state that the key to building a sustainable rural nursing workforce is ensuring that undergraduate nursing students in rural settings have a positive and well-supported experience. In the recently released Australian National Strategic Framework for Rural and Remote Health (Australian Health Ministers Advisory Council Rural Health Standing Committee, 2012), quality student education in health settings is identified as central to sustainable rural health delivery. Nursing students in Australia spend approximately 1000 h in unpaid, supernumerary placements over the course of a three or four year degree (Kenny et al., 2012). For paramedicine, there are no prescribed hours for student placement, but placement is integral to course accreditation. Given the central role of student placement for both nursing and paramedicine, we were surprised by our cursory review of the Australian literature that yielded few studies on the experiences of student supervisors in the rural context. Mills et al.'s (2010, p.10) integrative review on the status of rural nursing identified the importance of rural nurses as ‘translators of
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local culture’ and identified their role as crucial in supporting neophyte clinicians. More recently, researchers have identified the need to foster and develop clinical academic leadership in the rural context (Doherty et al., 2013; Bish et al., 2012), but an apparent lack of knowledge on the experiences of supervisors in the rural context makes clinical academic leadership development difficult. We were keen to complete a broader, international review to identify what is known about nursing and paramedic clinical supervisors' experiences in rural settings. Background Globally, student placement experiences in health settings are important for many reasons (Kilminster and Jolly, 2000). It socializes students into their future professional role and identity (Higgs, 2012). While student experience in health care settings is a feature of most health professional courses, universities and health care agencies, two of the main actors in preparing the future health workforce, have different views and interests in relation to supervision practices (Billett, 2001). Universities have a major interest in ensuring that their students have effective and productive placement experiences, because in most cases, placements are a requirement for course accreditation. In contrast, the prime objective of health care agencies is to ensure a sustainable workforce for the delivery of quality, safe and timely healthcare that meets efficiency and productivity indicators. This productivity imperative, based on ever tighter budgets and underresourced health care services, attenuates health care agencies' interest to offer placements, because in many instances, it requires staff take on the role of supervisor, in addition to their main clinical role. This often results in students being seen as a burden or a risk to productivity, which in turn places low priority and value on student supervision (Heath, 2002; Barton et al., 2005; Sanderson and Lea, 2012). From a student and staff perspective there are consequences, with poor experiences leading to student disenrollment or dissatisfaction (Leduq et al., 2012; Boyle et al., 2008; Lucas and McCall, 2013) and for supervisors', burn out, withdrawal from taking students on placement or even resignations (Sanderson and Lea, 2012). This situation creates a challenge for universities, especially within nursing and paramedicine, as their student intake increases and the competition amongst universities for placements escalates accordingly (Siggins Miller Consultants, 2012; Barnett et al., 2010; Magnusson et al., 2007). This competition amplifies the need to make effective use of placements and to understand what is required from students, supervisors and the workplace environment. Many student placement models have been developed worldwide. In some cases, researchers have reported on reducing the responsibility and time involved in supervising students by employing supervisors through universities (Sanderson and Lea, 2012; Lavender, 2013). University staff, government agencies, and health services have focused on developing learning and teaching resources for supervisors and providing training and support (Health Workforce Australia, 2011). Innovative approaches have addressed peer learning models (Hoffman et al., 2008), studentled clinics, where senior students mentor junior students (Grealich et al., 2013), and interprofessional placements where supervision is shared across professions (Jansen, 2008). Few studies have addressed the wider health care agencies' workplace learning environment (Grealich et al., 2013; Siggins Miller Consultants, 2012; Moscaritolo, 2009; Robinson et al., 2007). A comprehensive literature review and stakeholder consultation report completed by Siggins Miller Consultants (2012) documented key enablers and barriers to quality student placements. Authors of this report identified enablers that improve student placement experience including: a culture of quality; effective supervision; learning opportunities; effective communication and collaboration; and resources and facilities to conduct placements. In the report it is stated that two factors clearly hinder satisfaction and success in the health care learning environment: occupational stress; and workplace
incivility and aggression. The consultants identified that most enablers and barriers relate to socio-cultural aspects of the workplace, rather than to micro skills in supervising students. While the authors of the Siggins Miller report (2012) highlight enablers and barriers to quality student placements, the focus is on student needs rather than on supervisors' experiences and needs. Within the nursing and paramedicine literature a similar trend is evident. That is, there is a growing knowledge base on the experiences of students during health care placements (Williams et al., 2012; Lucas et al., 2013; Henderson, 2012; Wallin et al., 2013) but little is known about the experiences of supervisors and what they perceive as enablers and obstacles to their supervision practices. Methods A scoping review was undertaken to identify what is known about the experiences of rural nursing and paramedicine supervisors of undergraduate students. Scoping reviews are useful to map, collate and summarise existing literature on a topic. Unlike systematic reviews, the focus of a scoping review is not on the assessment of the quality of the research (O'Malley and Croucher, 2005), rather, the approach supports identification of a broader range of literature, including all types of study designs (Arksey and O'Malley, 2005). The work of Arksey and O'Malley provides a useful methodological framework for scoping reviews. For this study, we adopted their five-stage approach: identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarising and reporting results. Identifying the Research Question Arksey and O'Malley (2005, p.23) recommend that a broad question and key terms are central to ‘generate breadth of coverage’. As our aim was to capture a broad range of literature pertaining to the experiences of supervisors of nursing and paramedicine students, the research question ‘what is known about nursing and paramedicine clinical supervisors' experiences of their supervision practices in rural settings?’ guided the search strategy. Identifying Relevant Studies Researchers have identified the need to establish clear criteria to place some boundary around a study and achieve a balance between a thorough review and the practicalities of time and cost limitations (Kenny et al., 2013). In this study, key search terms were identified and the following Boolean search string was developed: supervisor* AND student* AND (nurs* OR paramedic*) AND work environment AND (region* OR rural OR remote). The use of truncated words and wild cards (in this instance *) allowed a broadening of the search to include all terms with the same root word. In order to refine this search, additional inclusion and exclusion criteria, consistent with our review purpose, were also developed. These are outlined in Table 1. An initial search of Google Scholar was carried out to determine the likely size and relevance of key terms, but the results were not included in our findings due to the lack of replicability of this search strategy (Giustini and Kamel Boulos, 2013). A search of the Cochrane Library failed to retrieve any registered Cochrane reviews. Databases searched included Academic Search Complete, Springer, Factiva, ProQuest, Ebsco, Informit, VOCEDplus and Scopus. Study Selection Using the developed search terms, 92 articles were identified. The title, abstract and keywords of the articles were scrutinised against the inclusion and exclusion criteria, with the research team involved in agreeing and confirming the elimination of irrelevant studies. Many articles that initially appeared relevant were excluded. For example,
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Sanderson and Lea (2012) explored experiences of clinical supervisors but had to be excluded because their clinical supervisors were employed within the university system. McCarthy and Murphy (2010) explored clinical supervisors' experiences, but had no focus on rural settings. Through the process of elimination, nine articles were identified that appeared to meet the inclusion criteria. Full text versions of these articles were read by a minimum of two team members. The ensuing discussions enabled us to further cull articles that did not match the inclusion and exclusion criteria. One such article was a position paper that critically discussed how to prepare supervisors for their role, without exploring their supervision experiences (Edwards, 2011). Through the process of refinement, five articles were identified as being directly relevant to the research question and matching the inclusion and exclusion criteria. Data Charting and Collation Consistent with the fourth stage of Arksey and O'Malley's framework, we developed summaries of each article and documented data related to author, journal, publication year, setting, country, research question or aim, and theoretical framework/research design (see Table 2). Summarising and Reporting Findings The final stage of Arksey and O'Malley's framework is the provision of an overview of the selected articles. As the purpose of this scoping review was to identify peer-reviewed articles that presented studies that specifically illuminated rural paramedicine and nursing student supervisors' experiences of their supervision practices, our reporting on the identified articles focuses on enablers and barriers for effective supervision as well as on key messages from each article and their recommendations for further research. Results and Discussion This scoping review study yielded five articles, all pertaining to nursing in countries as varied as Sweden, Belgium, Malaysia and Australia (two articles). There was a noticeable absence of articles relating to the experiences of supervisors of paramedicine students. Of the five articles in the nursing literature, two were written by the same authors, reducing research of clinical supervisors' experiences of workplace supervision to four research teams only. In what follows, we present the results and discussion under the headings enablers and barriers for effective supervision, key messages from each article and recommendations for further research. Enablers for Effective Supervision Within the five nursing articles, a recurring enabler of effective clinical supervision was perceived to be the quality of the relationship between the organisation and the university. Good preparation of courses and ongoing professional development were identified as
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important. Attention to relationships, courses and professional development was viewed as integral to ensuring that supervisors have the confidence and appropriate knowledge to teach and assess students (Huybrecht et al., 2011). Organisational factors, including acknowledgement of the responsibility associated with the supervisor role, information packages for students and supervisors (Bos et al., 2009), and receiving support from colleagues (Huybrecht et al., 2011) were seen as important for effective supervision. Continuous professional development opportunities provided by universities, together with constructive feedback, were described as central processes in becoming effective supervisors (Huybrecht et al., 2011). Authors of two articles (Chuan and Barnett, 2012; Reid-Searl and Happell, 2011) discussed the importance of reciprocity between students and supervisors as a key enabler. Furthermore, in these articles, positive attitudes and mutual respect of students and supervisors were seen as beneficial. Reid-Searl and Happell (2012) added supervisors' willingness to share their knowledge and preparedness to answer students' questions as key enablers for effective supervision. Barriers for Effective Supervision Lack of time and heavy workloads were reported as key barriers in the five articles reviewed (Huybrecht et al., 2011; Bos et al., 2009; Reid-Searl and Happell, 2011, 2012; Chuan and Barnett, 2012). Poor communication and support were seen as obstacles to quality supervisory practices. More specifically, Bos et al. (2009) listed lack of support from clinical managers and peers; and Reid-Searl and Happell (2011) discussed poor communication between university and supervisors as a barrier for effective supervision. An additional barrier, only mentioned by Reid-Searl and Happell (2011), was poor attitudes of supervisors towards students. At a skill level, Huybrecht et al. (2011) found poor teaching and assessing skills as barriers to positive supervision experiences. Lastly, Reid-Searl and Happell (2012) identified poor preparation and not valuing the supervision role as dominant barriers in their study. Key Messages From the Identified Articles Each of the five reviewed papers had different key messages or arguments. These were closely related to their unique research foci, within the theme of supervisors' experiences of workplace supervision. One argument, which was shared in two studies (Bos et al., 2009; ReidSearl and Happell, 2011), was the need to foster close relationships and strong cooperation between university and supervisors. Bos et al. (2009) found that a benefit of strong cooperation between university and supervisors was helping supervisors keep up-to-date with changes in nurse education. They highlighted the need for good support from clinical managers. In addition to communication with universities, Reid-Searl and Happell (2011) identified three other key themes that influenced supervisors' experiences: student attitudes that influence the quality of supervision provided; students feeling pressured to conform to, rather than to question clinical practices; and being sole assessor of students (closely linked to the previous theme). Huybrecht
Table 1 Inclusion and exclusion criteria. Criterion
Inclusion
Exclusion
Time period Language Type of article
January 2000 to December 2012 English Original research article published in a peer reviewed journal Nursing or paramedicine Rural, regional or remote International Supervisors of nursing or paramedicine students employed within the health care system
Any study outside these dates Non-English Any publication that was not original research, peer-reviewed, journal article and/or unpublished. For example, PhD theses, reports were excluded No reference to nursing or paramedicine No reference to rural, regional or remote Nil Studies that did not report the experiences of nursing or paramedicine student supervisors; studies that reported the experiences of clinical supervisors employed within the university system
Study focus Setting Geographical place of study Population and sample
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Table 2 Summary of identified and reviewed articles. Journal/year
Setting/supervision model
Country
Research question/aim
Bos, E., Anna Löfmark, Lena Törnkvist District nurses' experience of supervising nursing students in primary health care: A pre- and post-implementation questionnaire study
Nurse Education in Practice, 2009
Nursing Primary health care in regional and urban centres.
Sweden
Investigate district nurses' experience of supervising nursing Descriptive, quantitative design Evaluation study students in primary health care before and after the Questionnaire covered the following areas: implementation of a new supervision model
Huybrecht, S., Wim Loeckx, Yvo Quaeyhaegens, Danielle De Tobel, Wilhelm Mistiaen Mentoring in nursing education: Perceived characteristics of mentors and the consequences of mentorship Chuan, O. L., T. Barnett Student, tutor and staff nurse perceptions of the clinical learning environment
Nurse Education Today, 2011
Nursing Seven regional and university hospitals in Antwerp
Nurse Education in Practice, 2012
Reid-Searl, K., Brenda Happell Factors influencing the supervision of nursing students administering medication: The registered nurse perspective Reid-Searl, K., Happell, B. Supervising nursing students administering medication: a perspective from registered nurses
Collegian, 2011
Malaysia Describe and compare the perceptions of student nurses, Nursing staff nurses and nurse tutors towards the clinical learning Private hospital. environment (CLE) and to identify the key characteristics Staff nurses maintained a patient of CLE that enhanced or inhibited students' learning in a case load when they supervised Malaysian hospital student clinical instructors did not. Nursing Australia The aim of this study was to explore the opinions and Public health care facility in regional QLD insights of registered nurses regarding the supervision of nursing students administering medication.
Journal of Clinical Nursing Nursing, 2012 Health service in regional Queensl and from a spread of specialty areas including medical, surgical, accident and emergency mental health, paediatrics and maternity. Focus was on supervision of nursing students administering medication
Belgium
How mentors perceive themselves? Which problems do they encounter? What do mentors consider the advantages/drawbacks? What is the main source of help in mentoring students?
Australia Explore the attitudes, opinions and experiences of registered nurses with regard to the supervision of undergraduate nursing students during the administration of medications in the healthcare setting. By enhancing our understanding of the education and skill development of nursing students in this respect, the ability to produce registered nurses with safer practices in administering medication can be influenced
Theoretical framework/research design
1. Background, capabilities, skills: 12 items 2. Performance of supervision: 25 items opinions 3. Organisation of supervision: 14 items Questionnaire and semi-structured interviews.
Descriptive design using a structured, self-administered questionnaire with 0students, clinical supervisors and nurse staff (three groups)
Qualitative exploratory research Two focus groups
Qualitative exploratory design Focus groups
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Authors/title
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et al. (2011) found that it was important to clearly understand what was meant by being a supervisor. Chuan and Barnett (2012) highlighted that students and supervisors had different perceptions of the clinical learning environment. Students focused on learning needs, whereas supervisors focused on service needs. Their key argument was that these competing interests (service versus learning) could be overcome by identifying shared understanding between students and supervisors. Reid-Searl and Happell (2012) identified three key themes: standard of supervision; beneficial experience; and preparation for supervision. They not only argued that supervisors need to ensure they meet university requirements, but also asserted that supervisors need to regularly prepare for their supervision. Further Research Two research teams (Chuan and Barnett, 2012; Reid-Searl and Happell, 2011, 2012) offered very distinct recommendations for further research. Chuan and Barnett (2012) recommended further research using their questionnaire instrument, designed around their six characteristics needed for a quality clinical learning environment: workplace atmosphere, supervision by staff nurses and the clinical instructor, student satisfaction, the theory–practice gap, and peer support. Reid-Searl and Happell (2011) recommended exploring clinical practice models that best suit students' learning needs. They especially mentioned exploring shared assessment practices between staff employed within the university system and health care agencies. ReidSearl and Happell (2012) recommended exploration of the relationship between supervision and error prevention in administering medication. Because these recommendations for further research were based on their respective study foci, of comparing nursing students, staff and tutors' perceptions of the clinical learning environment (Chuan and Barnett, 2012), and the administration of medication by student nurses (Reid-Searl and Happell, 2011, 2012), it is not surprising that they provide no recommendation about developing a better understanding of supervisors' experiences. It should be noted that even though these articles reported on studies conducted within rural contexts, there was no explicit mention of the ‘rural’ experience and their recommendations for future research did not include the experiences of supervising in rural settings. Conclusion From this scoping review of nursing and paramedicine supervisors' perspectives of their experiences in supervising students in rural workplaces we conclude that supervisors' experiences of workplace supervision in rural settings are an under-researched, or perhaps an emerging area of research. Our review highlighted a lack of connection between the rural context and supervisors' experiences and a lack of discussion about rural specific enablers and barriers. Focusing on training and support to enhance the capacity of individual supervisors is an important, yet potentially narrow and unsustainable approach. It does not take into account the impact of workplace learning culture and the importance of this culture in enhancing rural supervision practices and experiences. We argue that there is a need to conduct further research in supervision, from a rural perspective, focusing on shared responsibility, organisational support, and the tension between practice and supervision. Further research is needed to explore supervisors' capacity for agency and their awareness of the sociomaterial forces in rural settings that shape their supervision experiences. References Arksey, H., O'Malley, L., 2005. Scoping studies: towards a methodological framework. Int. J. Soc. Res. Methodol. 8, 19–32. http://dx.doi.org/10.1080/13645579.2012.706019. Australian Health Ministers Advisory Council Rural Health Standing Committee, 2012. The National Strategic Framework for Rural and Remote Health. Department of Health and Ageing, Canberra.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Review
Supervisors' experiences of workplace supervision of nursing and paramedic students in rural settings: A scoping review Franziska Trede a,⁎, Celina McEwen a,1, Amanda Kenny b,2, Peter O'Meara b,3 a b
The Education For Practice Institute, Charles Sturt University, Locked Bag 450, Silverwater, NSW 2128, Australia La Trobe Rural Health School, Faculty of Health Sciences, La Trobe University Health Sciences, Bendigo, VIC 3550, Australia
a r t i c l e
i n f o
Article history: Accepted 7 October 2013
Keywords: Supervision Supervisor Rural Nursing Paramedicine
s u m m a r y Objectives: We present our findings from a scoping review that sought to identify what is known about nursing and paramedic clinical supervisors' experiences of their supervision practices in rural settings. Our interest in these two groups is based on the central role that nurses and paramedics play in rural health care. Design: Scoping reviews support identification of a broad range of literature, including all types of study designs. We adopted Arksey and O'Malley's five-stage approach: identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarising and reporting results. Data Sources: Databases searched included Academic Search Complete, Springer, Factiva, ProQuest, Ebsco, Informit, VOCEDplus and Scopus. Review Method: Based on our research question and inclusion and exclusion criteria we selected relevant literature and summarised and reported it using Arksey and O'Malley's framework. Results: The review yielded five articles from four countries: Sweden, Belgium, Malaysia and Australia. Conclusion: From this scoping review, we identified key themes related to supervisors' experiences, including clarification of expectations, support from managers and colleagues, the need for shared understanding between university, students and supervisors and required skills and competence in supervising students. © 2013 Elsevier Ltd. All rights reserved.
Introduction In this article, we present our findings from a scoping review of the literature on supervisors' perspectives of their experiences in supervising nursing and paramedic students undertaking rural placements. Understanding supervisors' perspectives can help identify issues associated with student supervision and develop understanding of the enablers that support quality supervision practices. Many different definitions, roles and understandings are used for the term supervisor such as mentor, preceptor and educator (Billay and Yonge, 2004; McCarthy and Murphy, 2010). For the purpose of our review, we defined supervisors as health care professionals employed within a health care agency who mentor, monitor, teach, provide feedback and assess undergraduate students. In our review, the key focus was on supervisors of nursing and paramedic students. Our focus on rural, which we define as nonmetropolitan, was triggered by findings from a study by Siggins Miller Consultants (2012) that identified that workforce maldistribution,
⁎ Corresponding author. Tel./fax: +61 2 9752 9003. E-mail addresses: [email protected] (F. Trede), [email protected] (C. McEwen), [email protected] (A. Kenny), [email protected] (P. O'Meara). 1 Tel.: +61 2 9752 9013; fax: +61 2 9746 3647. 2 Tel.: +61 3 5444 7545. 3 Tel.: +61 3 5444 7870. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.10.003
under-resourcing, geographical isolation and poor access to the internet (characteristics of clinical rural settings) have a major impact on quality student supervision. The focus on nursing and paramedicine was fuelled by the central role that these two groups play in ensuring sustainable health service delivery in rural areas (Duckett and Kenny, 2000; Kenny and Duckett, 2003; Mulholland, 2010). In a study by Mulholland (2010), a dearth of literature relating to rural paramedic education was identified. In the rural nursing literature, Kenny and Duckett (2003) state that the key to building a sustainable rural nursing workforce is ensuring that undergraduate nursing students in rural settings have a positive and well-supported experience. In the recently released Australian National Strategic Framework for Rural and Remote Health (Australian Health Ministers Advisory Council Rural Health Standing Committee, 2012), quality student education in health settings is identified as central to sustainable rural health delivery. Nursing students in Australia spend approximately 1000 h in unpaid, supernumerary placements over the course of a three or four year degree (Kenny et al., 2012). For paramedicine, there are no prescribed hours for student placement, but placement is integral to course accreditation. Given the central role of student placement for both nursing and paramedicine, we were surprised by our cursory review of the Australian literature that yielded few studies on the experiences of student supervisors in the rural context. Mills et al.'s (2010, p.10) integrative review on the status of rural nursing identified the importance of rural nurses as ‘translators of
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local culture’ and identified their role as crucial in supporting neophyte clinicians. More recently, researchers have identified the need to foster and develop clinical academic leadership in the rural context (Doherty et al., 2013; Bish et al., 2012), but an apparent lack of knowledge on the experiences of supervisors in the rural context makes clinical academic leadership development difficult. We were keen to complete a broader, international review to identify what is known about nursing and paramedic clinical supervisors' experiences in rural settings. Background Globally, student placement experiences in health settings are important for many reasons (Kilminster and Jolly, 2000). It socializes students into their future professional role and identity (Higgs, 2012). While student experience in health care settings is a feature of most health professional courses, universities and health care agencies, two of the main actors in preparing the future health workforce, have different views and interests in relation to supervision practices (Billett, 2001). Universities have a major interest in ensuring that their students have effective and productive placement experiences, because in most cases, placements are a requirement for course accreditation. In contrast, the prime objective of health care agencies is to ensure a sustainable workforce for the delivery of quality, safe and timely healthcare that meets efficiency and productivity indicators. This productivity imperative, based on ever tighter budgets and underresourced health care services, attenuates health care agencies' interest to offer placements, because in many instances, it requires staff take on the role of supervisor, in addition to their main clinical role. This often results in students being seen as a burden or a risk to productivity, which in turn places low priority and value on student supervision (Heath, 2002; Barton et al., 2005; Sanderson and Lea, 2012). From a student and staff perspective there are consequences, with poor experiences leading to student disenrollment or dissatisfaction (Leduq et al., 2012; Boyle et al., 2008; Lucas and McCall, 2013) and for supervisors', burn out, withdrawal from taking students on placement or even resignations (Sanderson and Lea, 2012). This situation creates a challenge for universities, especially within nursing and paramedicine, as their student intake increases and the competition amongst universities for placements escalates accordingly (Siggins Miller Consultants, 2012; Barnett et al., 2010; Magnusson et al., 2007). This competition amplifies the need to make effective use of placements and to understand what is required from students, supervisors and the workplace environment. Many student placement models have been developed worldwide. In some cases, researchers have reported on reducing the responsibility and time involved in supervising students by employing supervisors through universities (Sanderson and Lea, 2012; Lavender, 2013). University staff, government agencies, and health services have focused on developing learning and teaching resources for supervisors and providing training and support (Health Workforce Australia, 2011). Innovative approaches have addressed peer learning models (Hoffman et al., 2008), studentled clinics, where senior students mentor junior students (Grealich et al., 2013), and interprofessional placements where supervision is shared across professions (Jansen, 2008). Few studies have addressed the wider health care agencies' workplace learning environment (Grealich et al., 2013; Siggins Miller Consultants, 2012; Moscaritolo, 2009; Robinson et al., 2007). A comprehensive literature review and stakeholder consultation report completed by Siggins Miller Consultants (2012) documented key enablers and barriers to quality student placements. Authors of this report identified enablers that improve student placement experience including: a culture of quality; effective supervision; learning opportunities; effective communication and collaboration; and resources and facilities to conduct placements. In the report it is stated that two factors clearly hinder satisfaction and success in the health care learning environment: occupational stress; and workplace
incivility and aggression. The consultants identified that most enablers and barriers relate to socio-cultural aspects of the workplace, rather than to micro skills in supervising students. While the authors of the Siggins Miller report (2012) highlight enablers and barriers to quality student placements, the focus is on student needs rather than on supervisors' experiences and needs. Within the nursing and paramedicine literature a similar trend is evident. That is, there is a growing knowledge base on the experiences of students during health care placements (Williams et al., 2012; Lucas et al., 2013; Henderson, 2012; Wallin et al., 2013) but little is known about the experiences of supervisors and what they perceive as enablers and obstacles to their supervision practices. Methods A scoping review was undertaken to identify what is known about the experiences of rural nursing and paramedicine supervisors of undergraduate students. Scoping reviews are useful to map, collate and summarise existing literature on a topic. Unlike systematic reviews, the focus of a scoping review is not on the assessment of the quality of the research (O'Malley and Croucher, 2005), rather, the approach supports identification of a broader range of literature, including all types of study designs (Arksey and O'Malley, 2005). The work of Arksey and O'Malley provides a useful methodological framework for scoping reviews. For this study, we adopted their five-stage approach: identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarising and reporting results. Identifying the Research Question Arksey and O'Malley (2005, p.23) recommend that a broad question and key terms are central to ‘generate breadth of coverage’. As our aim was to capture a broad range of literature pertaining to the experiences of supervisors of nursing and paramedicine students, the research question ‘what is known about nursing and paramedicine clinical supervisors' experiences of their supervision practices in rural settings?’ guided the search strategy. Identifying Relevant Studies Researchers have identified the need to establish clear criteria to place some boundary around a study and achieve a balance between a thorough review and the practicalities of time and cost limitations (Kenny et al., 2013). In this study, key search terms were identified and the following Boolean search string was developed: supervisor* AND student* AND (nurs* OR paramedic*) AND work environment AND (region* OR rural OR remote). The use of truncated words and wild cards (in this instance *) allowed a broadening of the search to include all terms with the same root word. In order to refine this search, additional inclusion and exclusion criteria, consistent with our review purpose, were also developed. These are outlined in Table 1. An initial search of Google Scholar was carried out to determine the likely size and relevance of key terms, but the results were not included in our findings due to the lack of replicability of this search strategy (Giustini and Kamel Boulos, 2013). A search of the Cochrane Library failed to retrieve any registered Cochrane reviews. Databases searched included Academic Search Complete, Springer, Factiva, ProQuest, Ebsco, Informit, VOCEDplus and Scopus. Study Selection Using the developed search terms, 92 articles were identified. The title, abstract and keywords of the articles were scrutinised against the inclusion and exclusion criteria, with the research team involved in agreeing and confirming the elimination of irrelevant studies. Many articles that initially appeared relevant were excluded. For example,
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Sanderson and Lea (2012) explored experiences of clinical supervisors but had to be excluded because their clinical supervisors were employed within the university system. McCarthy and Murphy (2010) explored clinical supervisors' experiences, but had no focus on rural settings. Through the process of elimination, nine articles were identified that appeared to meet the inclusion criteria. Full text versions of these articles were read by a minimum of two team members. The ensuing discussions enabled us to further cull articles that did not match the inclusion and exclusion criteria. One such article was a position paper that critically discussed how to prepare supervisors for their role, without exploring their supervision experiences (Edwards, 2011). Through the process of refinement, five articles were identified as being directly relevant to the research question and matching the inclusion and exclusion criteria. Data Charting and Collation Consistent with the fourth stage of Arksey and O'Malley's framework, we developed summaries of each article and documented data related to author, journal, publication year, setting, country, research question or aim, and theoretical framework/research design (see Table 2). Summarising and Reporting Findings The final stage of Arksey and O'Malley's framework is the provision of an overview of the selected articles. As the purpose of this scoping review was to identify peer-reviewed articles that presented studies that specifically illuminated rural paramedicine and nursing student supervisors' experiences of their supervision practices, our reporting on the identified articles focuses on enablers and barriers for effective supervision as well as on key messages from each article and their recommendations for further research. Results and Discussion This scoping review study yielded five articles, all pertaining to nursing in countries as varied as Sweden, Belgium, Malaysia and Australia (two articles). There was a noticeable absence of articles relating to the experiences of supervisors of paramedicine students. Of the five articles in the nursing literature, two were written by the same authors, reducing research of clinical supervisors' experiences of workplace supervision to four research teams only. In what follows, we present the results and discussion under the headings enablers and barriers for effective supervision, key messages from each article and recommendations for further research. Enablers for Effective Supervision Within the five nursing articles, a recurring enabler of effective clinical supervision was perceived to be the quality of the relationship between the organisation and the university. Good preparation of courses and ongoing professional development were identified as
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important. Attention to relationships, courses and professional development was viewed as integral to ensuring that supervisors have the confidence and appropriate knowledge to teach and assess students (Huybrecht et al., 2011). Organisational factors, including acknowledgement of the responsibility associated with the supervisor role, information packages for students and supervisors (Bos et al., 2009), and receiving support from colleagues (Huybrecht et al., 2011) were seen as important for effective supervision. Continuous professional development opportunities provided by universities, together with constructive feedback, were described as central processes in becoming effective supervisors (Huybrecht et al., 2011). Authors of two articles (Chuan and Barnett, 2012; Reid-Searl and Happell, 2011) discussed the importance of reciprocity between students and supervisors as a key enabler. Furthermore, in these articles, positive attitudes and mutual respect of students and supervisors were seen as beneficial. Reid-Searl and Happell (2012) added supervisors' willingness to share their knowledge and preparedness to answer students' questions as key enablers for effective supervision. Barriers for Effective Supervision Lack of time and heavy workloads were reported as key barriers in the five articles reviewed (Huybrecht et al., 2011; Bos et al., 2009; Reid-Searl and Happell, 2011, 2012; Chuan and Barnett, 2012). Poor communication and support were seen as obstacles to quality supervisory practices. More specifically, Bos et al. (2009) listed lack of support from clinical managers and peers; and Reid-Searl and Happell (2011) discussed poor communication between university and supervisors as a barrier for effective supervision. An additional barrier, only mentioned by Reid-Searl and Happell (2011), was poor attitudes of supervisors towards students. At a skill level, Huybrecht et al. (2011) found poor teaching and assessing skills as barriers to positive supervision experiences. Lastly, Reid-Searl and Happell (2012) identified poor preparation and not valuing the supervision role as dominant barriers in their study. Key Messages From the Identified Articles Each of the five reviewed papers had different key messages or arguments. These were closely related to their unique research foci, within the theme of supervisors' experiences of workplace supervision. One argument, which was shared in two studies (Bos et al., 2009; ReidSearl and Happell, 2011), was the need to foster close relationships and strong cooperation between university and supervisors. Bos et al. (2009) found that a benefit of strong cooperation between university and supervisors was helping supervisors keep up-to-date with changes in nurse education. They highlighted the need for good support from clinical managers. In addition to communication with universities, Reid-Searl and Happell (2011) identified three other key themes that influenced supervisors' experiences: student attitudes that influence the quality of supervision provided; students feeling pressured to conform to, rather than to question clinical practices; and being sole assessor of students (closely linked to the previous theme). Huybrecht
Table 1 Inclusion and exclusion criteria. Criterion
Inclusion
Exclusion
Time period Language Type of article
January 2000 to December 2012 English Original research article published in a peer reviewed journal Nursing or paramedicine Rural, regional or remote International Supervisors of nursing or paramedicine students employed within the health care system
Any study outside these dates Non-English Any publication that was not original research, peer-reviewed, journal article and/or unpublished. For example, PhD theses, reports were excluded No reference to nursing or paramedicine No reference to rural, regional or remote Nil Studies that did not report the experiences of nursing or paramedicine student supervisors; studies that reported the experiences of clinical supervisors employed within the university system
Study focus Setting Geographical place of study Population and sample
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Table 2 Summary of identified and reviewed articles. Journal/year
Setting/supervision model
Country
Research question/aim
Bos, E., Anna Löfmark, Lena Törnkvist District nurses' experience of supervising nursing students in primary health care: A pre- and post-implementation questionnaire study
Nurse Education in Practice, 2009
Nursing Primary health care in regional and urban centres.
Sweden
Investigate district nurses' experience of supervising nursing Descriptive, quantitative design Evaluation study students in primary health care before and after the Questionnaire covered the following areas: implementation of a new supervision model
Huybrecht, S., Wim Loeckx, Yvo Quaeyhaegens, Danielle De Tobel, Wilhelm Mistiaen Mentoring in nursing education: Perceived characteristics of mentors and the consequences of mentorship Chuan, O. L., T. Barnett Student, tutor and staff nurse perceptions of the clinical learning environment
Nurse Education Today, 2011
Nursing Seven regional and university hospitals in Antwerp
Nurse Education in Practice, 2012
Reid-Searl, K., Brenda Happell Factors influencing the supervision of nursing students administering medication: The registered nurse perspective Reid-Searl, K., Happell, B. Supervising nursing students administering medication: a perspective from registered nurses
Collegian, 2011
Malaysia Describe and compare the perceptions of student nurses, Nursing staff nurses and nurse tutors towards the clinical learning Private hospital. environment (CLE) and to identify the key characteristics Staff nurses maintained a patient of CLE that enhanced or inhibited students' learning in a case load when they supervised Malaysian hospital student clinical instructors did not. Nursing Australia The aim of this study was to explore the opinions and Public health care facility in regional QLD insights of registered nurses regarding the supervision of nursing students administering medication.
Journal of Clinical Nursing Nursing, 2012 Health service in regional Queensl and from a spread of specialty areas including medical, surgical, accident and emergency mental health, paediatrics and maternity. Focus was on supervision of nursing students administering medication
Belgium
How mentors perceive themselves? Which problems do they encounter? What do mentors consider the advantages/drawbacks? What is the main source of help in mentoring students?
Australia Explore the attitudes, opinions and experiences of registered nurses with regard to the supervision of undergraduate nursing students during the administration of medications in the healthcare setting. By enhancing our understanding of the education and skill development of nursing students in this respect, the ability to produce registered nurses with safer practices in administering medication can be influenced
Theoretical framework/research design
1. Background, capabilities, skills: 12 items 2. Performance of supervision: 25 items opinions 3. Organisation of supervision: 14 items Questionnaire and semi-structured interviews.
Descriptive design using a structured, self-administered questionnaire with 0students, clinical supervisors and nurse staff (three groups)
Qualitative exploratory research Two focus groups
Qualitative exploratory design Focus groups
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Authors/title
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et al. (2011) found that it was important to clearly understand what was meant by being a supervisor. Chuan and Barnett (2012) highlighted that students and supervisors had different perceptions of the clinical learning environment. Students focused on learning needs, whereas supervisors focused on service needs. Their key argument was that these competing interests (service versus learning) could be overcome by identifying shared understanding between students and supervisors. Reid-Searl and Happell (2012) identified three key themes: standard of supervision; beneficial experience; and preparation for supervision. They not only argued that supervisors need to ensure they meet university requirements, but also asserted that supervisors need to regularly prepare for their supervision. Further Research Two research teams (Chuan and Barnett, 2012; Reid-Searl and Happell, 2011, 2012) offered very distinct recommendations for further research. Chuan and Barnett (2012) recommended further research using their questionnaire instrument, designed around their six characteristics needed for a quality clinical learning environment: workplace atmosphere, supervision by staff nurses and the clinical instructor, student satisfaction, the theory–practice gap, and peer support. Reid-Searl and Happell (2011) recommended exploring clinical practice models that best suit students' learning needs. They especially mentioned exploring shared assessment practices between staff employed within the university system and health care agencies. ReidSearl and Happell (2012) recommended exploration of the relationship between supervision and error prevention in administering medication. Because these recommendations for further research were based on their respective study foci, of comparing nursing students, staff and tutors' perceptions of the clinical learning environment (Chuan and Barnett, 2012), and the administration of medication by student nurses (Reid-Searl and Happell, 2011, 2012), it is not surprising that they provide no recommendation about developing a better understanding of supervisors' experiences. It should be noted that even though these articles reported on studies conducted within rural contexts, there was no explicit mention of the ‘rural’ experience and their recommendations for future research did not include the experiences of supervising in rural settings. Conclusion From this scoping review of nursing and paramedicine supervisors' perspectives of their experiences in supervising students in rural workplaces we conclude that supervisors' experiences of workplace supervision in rural settings are an under-researched, or perhaps an emerging area of research. Our review highlighted a lack of connection between the rural context and supervisors' experiences and a lack of discussion about rural specific enablers and barriers. Focusing on training and support to enhance the capacity of individual supervisors is an important, yet potentially narrow and unsustainable approach. It does not take into account the impact of workplace learning culture and the importance of this culture in enhancing rural supervision practices and experiences. We argue that there is a need to conduct further research in supervision, from a rural perspective, focusing on shared responsibility, organisational support, and the tension between practice and supervision. Further research is needed to explore supervisors' capacity for agency and their awareness of the sociomaterial forces in rural settings that shape their supervision experiences. References Arksey, H., O'Malley, L., 2005. Scoping studies: towards a methodological framework. Int. J. Soc. Res. Methodol. 8, 19–32. http://dx.doi.org/10.1080/13645579.2012.706019. Australian Health Ministers Advisory Council Rural Health Standing Committee, 2012. The National Strategic Framework for Rural and Remote Health. Department of Health and Ageing, Canberra.
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