Papers from the 9th Cambridge Conference

Effective supervision in clinical practice settings: a literature

review*

S M Kilminster & B C Jolly

Context Clinical supervision has a vital role in post- tor for the effectiveness of supervision, more important
graduate and, to some extent, undergraduate medical than the supervisory methods used. Feedback is
education. However it is probably the least investigated, essential and must be clear. It is important that the
discussed and developed aspect of clinical education. trainee has some control over and input into the
This large-scale, interdisciplinary review of literature supervisory process. Finding suf®cient time for super-
addressing supervision is the ®rst from a medical vision can be a problem. Trainee behaviours and atti-
education perspective. tudes towards supervision require more investigation;
Purpose To review the literature on effective supervi- some behaviours are detrimental both to patient care
sion in practice settings in order to identify what is and learning. Current supervisory practice in medicine
known about effective supervision. has very little empirical or theoretical basis. This review
demonstrates the need for more structured and meth-
Content The empirical basis of the literature is
odologically sound programmes of research into
discussed and the literature reviewed to identify
supervision in practice settings so that detailed models
understandings and de®nitions of supervision and its
of effective supervision can be developed and thereby
purpose; theoretical models of supervision; availability,
inform practice.
structure and content of supervision; effective supervi-
sion; skills and qualities of effective supervisors; and Keywords Clinical clerkship, methods; education,
supervisor training and its effectiveness. medical, *methods; education, medical, graduate,
methods; preceptorship, *standards, methods; rev
Conclusions The evidence only partially answers our
2 academic.
original questions and suggests others. The supervision
relationship is probably the single most important fac- Medical Education 2000;34:827±840

Clinical supervision has a vital role in postgraduate

Introduction
medical education and, to some extent, undergrad-
uate medical education and yet it is probably the least There is a limited amount of published medical literature
investigated, discussed and developed aspect of addressing supervision; in particular, there are few
clinical teaching. The purpose of this paper is to empirical studies. Supervisory processes in related pro-
review the literature on effective supervision in fessions have potential relevance for medicine because
practice settings to identify what is known about they can offer relevant skills and insights; consequently,
effective supervision this review has included appropriate literature from other
healthcare professions ± particularly nursing, and from
social work, teaching, psychology and counselling. The
literature search was across academic and professional
disciplines (see Table 1).
*This paper was produced as part of a Department of Health funded
project `Good supervision: Guiding the clinical educator of the 21st The review excluded literature relating to research
century'. A previous version was used as a background paper for supervision. Although some counselling and psycho-
Cambridge Conference IX. therapy literature has been included in the review,
Department of Medical Education, University of Shef®eld, Northern articles including detail about transference and counter
1 General Hospital, Shef®eld, UK
transference issues and those that concentrate on the
Correspondence: S M Kilminster, Department of Medical Education,
University of Shef®eld, Northern General Hospital, Herries Rd, therapeutic aspects of the supervision relationship have
Shef®eld S5 7AU, UK been excluded.

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828 Effective supervision in clinical practice settings · S M Kilminster & B C Jolly

statistics. Some were due to piecemeal analysis. Thirty-

Structure and content of the review
two of 55 studies had research design problems that
Supervision is a complex activity, occurring in a variety invalidated their ®ndings. Ellis et al.2 assessed clinical
of settings, has various de®nitions, functions and modes supervision research from 1981 to 1993 against major
of delivery. Most importantly, it is an interpersonal methodological validity threats. They identi®ed nu-
exchange. This complexity means that research into merous methodological problems which they say are
supervisory practice presents methodological problems probably due to a shift to `pragmatic' ®eld studies
and adequate research methodologies have yet to be research and argue that `The three central remedies [to
established. Many reviewed articles had some empirical improve the research] are explicating theory, de®ning
aspect; although in some cases this aspect was very weak. constructs and formulating unambiguous hypotheses'
(p. 45).
Although many of the studies had clear hypotheses,
Methodological problems
very few de®ned constructs or made any theoretical
Two counselling and psychotherapy reviews exemplify linkages.3 Measurement of the supervision process
1
some of these problems. Fong et al. reviewed all the and supervision outcomes is dif®cult;4,5 most of
articles submitted in the instruments are
one year to a partic- standardized self-
ular journal (Counselor Key learning points report measures rely-
Education and Super- · We suggest the following de®nition of supervision for
ing on the perceptions
visor). From 111 medicine: the provision of monitoring, guidance and
of supervisee, super-
manuscripts, 57 were feedback on matters of personal, professional and
visor and client. These
research based and educational development in the context of the doctor's
present a major meth-
80% of these were care of patients. This would include the ability to
odological problem in
descriptive studies. anticipate a doctor's strengths and weaknesses in partic-
deciding, how, if at all,
Error types were ular clinical situations in order to maximize patient safety.
self-reported changes
determined from the · There is evidence that supervision has a positive effect on
or improvements af-
blind reviews of patient outcome and that lack of supervision is harmful
fect client outcomes.
the articles. Research for patients.
The literature
design errors included · The quality of the relationship between supervisor and
searches identi®ed
lack of a conceptual trainee is probably the single most important factor for
approximately 300
base; absent/unclear effective supervision.
relevant papers and
research questions; in- · Current supervisory practice in medicine has little empiri-
books. Much of the
adequate samples; un- cal or theoretical basis.
empirical work was
reliable/inappropriate small scale, exploratory
incidents and other and qualitative. Hence
problems meaning that the ®ndings were not general- it was neither appropriate to develop strong inclusion
izable. Analysis errors were mainly due to misuse of criteria for this review nor possible to perform meta-

Table 1 Databases searched and search terms used

Database Subject areas Search terms

MEDLINE Medicine and health care 1992 onwards.

Clinical supervision, teaching methods and supervision;
teaching standards and supervision; clinical competence and
supervision; mentoring; preceptorship; resident supervision.
Cinahl Nursing and allied health Supervision; clinical supervision.
British Education Index (BEI) Education Supervision; clinical supervision.
ERIC Education Supervision; clinical supervision.
International ERIC Education Supervision; clinical supervision.
Soc®le Sociology including social Supervision; clinical supervision.
work literature
PsychLit Psychology Supervision; clinical supervision.

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Effective supervision in clinical practice settings · S M Kilminster & B C Jolly 829

analyses. Furthermore, no other large-scale, interdisci- nursing28±31; social work27; educational psychology32,33
plinary review (nor any review of supervision in medi- and teaching.34
cine) was found. This review will have an additional Various UK documents relating to postgraduate
bibliographic function. The approach adopted was to medical education training give guidance on supervi-
examine the literature to identify what it could contribute sion but not a de®nition.35±37 Elements in this
towards answering the following questions: guidance include ensuring the safety of the trainee
and patient in the course of clinical care; ensuring an
· What are the understandings and de®nitions of
appropriate level and amount of clinical duties;
supervision and its purposes?
monitoring progress; feedback on performance, both
· What is the empirical basis for supervision.
informally and through appraisal; initial and con-
· What are the theoretical models of supervision?
tinuing education planning; ensuring provision of
· How is supervision delivered ± what is its structure
careers advice.
and content?
A summary is presented in Table 2.
· Is supervision effective and how can this be deter-
mined?
· What skills and qualities do effective supervisors Theoretical models of supervision
need?
There is little discussion of theoretical models in the
· What training do supervisors need and how can its
medical literature although Bowen and Carline38
effectiveness be determined?
argue that social learning theory describes the process
· Does the literature describe any other issues and
of professionalization. Green39 used Schmidt et al.'s40
dif®culties? 
theory of clinical reasoning to develop a theoretical
account of effective clinical psychology supervision as
Understandings and de®nitions of supervision contributing to the experiential learning cycle. Most
and its purpose models, certainly in the nursing literature,19,41±43 tend
to be narrative and philosophical with little or no
Most de®nitions of supervision emphasize promoting
empirical basis.44 Most supervision models
professional development and ensuring patient/client
support an instrumental rather than a questioning
safety.6±13 Emphases vary according to professional
approach.45,46
ethos. Supervision is usually understood as a distinct
Counselling, psychotherapy, social work and nursing
intervention which is partly hierarchical and evalua-
sources contain most discussion of models and theoret-
tive14±16 although there is some debate, mostly in
ical approaches to supervision.47±50 The content and
nursing, about whether a supervisor should also be a
style of supervision will be affected by whatever model is
manager.17±21 There is similar debate as to whether the
adopted. Counselling and psychotherapy literature
supervisor should also be the assessor.22,23 In some
offers various process and developmental models16,51±56
management literature supervision is seen as a form of
indicating that supervision needs vary according to the
quality assurance.24,25
trainees' experience and level of training. There is some
De®nitions of supervision embody understandings
about its purposes and functions. Probably the most
in¯uential formulation of the functions of supervision
Table 2 Understandings and de®nitions of supervision and its
in the UK literature is that of Bridget Proctor26 who
purpose ± summary
outlined three functions of supervision (based on those
de®ned by Kadushin27) ± normative (administrative),
There appears to be general agreement that the essential aspects
formative (educational), and restorative (supportive).
of supervision are that it should ensure patient/client safety and
The latter's work was empirically based whereas Proc- promote professional development.
tor's was not. This idea of three functions or roles of There is also general agreement that supervision has three
supervision ± management, education and support ± is functions ± educational, supportive and managerial or
re¯ected across professions; for example, medicine23; administrative.
On the basis of the literature review we suggest the following
de®nition of supervision for medicine: the provision of
monitoring, guidance and feedback on matters of personal,
  Note on terms: Supervisee: across the professions not all those
professional and educational development in the context of the
supervised are de®ned as trainees, some are also novice, or indeed
expert, practitioners. The term supervisee is frequently used in the
doctor's care of patients. This would include the ability to
literature and is used here where necessary. Patients/clients: used as an anticipate a doctor's strengths and weaknesses in particular
overarching term to refer to all those (excluding colleagues) with clinical situations in order to maximize patient safety.
whom professionals work.

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830 Effective supervision in clinical practice settings · S M Kilminster & B C Jolly

empirical support for this idea although there have been amount of supervision received by surgical SHOs and
few empirical tests of theoretical models of supervision. registrars before they operate unsupervised.63 Psychi-
Glickman's Developmental Supervision approach atry trainees do not always receive the stipulated min-
suggests the approach must be relevant to the trainees imum supervision64,65 and are not always satis®ed with
conceptual level. This was tested57 as part of an extensive levels of supervision.66 Problems with the extent and
programme to improve the teaching of physics, availability of supervision have also been identi®ed in
mechanics and electronics, that included personalized other professions, for example nursing;67 educational
supervision for the participating teachers, further train- psychology68,69 and social work.70
ing in their academic discipline and the provision of
teaching materials. The supervision approach was varied
Structure and content of supervision
according to the researchers' assessment of the teacher's
conceptual level (based on their ability to de®ne and The environment in which learning takes place pro-
solve problems) ± where this was low a directive approach foundly affects what is learnt and the learners'
was used; where the conceptual level was medium a responses; clinical settings which are considered to have
collaborative approach was used and where it was high a a positive orientation to teaching are also usually seen
non-directive approach was used. The authors found `to provide high quality supervision, good social sup-
both quantitative and qualitative changes in the students port, appropriate levels of autonomy, variety and
and concluded that the supervision process should be workload'71 (p. 706).
matched to the conceptual levels in the context of the Generally, feedback is perceived positively by train-
school system, programme goals and needs. There are ees.70,72 A questionnaire survey of SHOs and their
some supporting ®ndings from work on counselling and working conditions found that the better the perceived
psychotherapy students.58 feedback the more competent the SHO felt, the less
This section is summarized in Table 3. overwhelmed by responsibility they were and the better
their relationship with senior staff.73
There is a disparity in supervisors' and trainees' views
Availability, structure and content
about the amount of time spent on case review.
of supervision in health care professions
Trainees thought too much time was spent on this at
Supervision can occur `on the job', usually while a the expense of theoretical, career and teaching issues.
practical task is being carried out; informally; in a Therefore the supervision relationship should begin
one-to-one meeting; in peer supervision; in group with discussion about structure, systematic review,
supervision (with or without a facilitator); and in net- planning time to cover all areas, deciding who is
working (where not all participants work in the same responsible for raising each topic and how and when
place and/or in the same profession).48,59 the supervision process will be reviewed.65 Supervision
of Specialist Registrars (SpRs) should have ground
rules, be uninterrupted, be ¯exible, have learning
Availability
objectives, include record keeping and liaison with the
Surveys have found that supervision in the UK programme director. Its content should encompass
is inadequate ± of pre-registration house of®cers clinical management, teaching and research; manage-
(PRHOs);60 of hospital vocational training for General ment and administration; pastoral care; interpersonal
Practitioners (GPs);61 of senior house of®cers (SHOs) skills and personal development.15,74 Ritter et al.75
in the Out-patient department although they were sat- argue that the supervision contract is necessary to cre-
is®ed with supervision on the ward.62 There is wide ate a formal structure and continuity. The contract
variation beyond individual variations in learning in the should include such issues as the frequency and

Table 3 Theoretical models of supervision ± summary

Various models are presented in the psychotherapy, social work and nursing literature.
Most models stress the need to use supervision approaches that are appropriate to the trainee's level of experience and training. There
is limited empirical support for this proposition.
There are no adequate theoretical accounts of supervision in medicine; such an account of supervision in medicine would draw on ideas
developed in adult learning theories, experiential and work-based learning as well as understandings about apprenticeship. The
problem-based learning approach could also have relevance.

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 Effective supervision in clinical practice settings · S M Kilminster & B C Jolly 831

duration of supervision, appraisal and assessment, goal effect dif®culty by examining the effects of supervision
setting, focus and written requirements.28,76 on the trainee/supervisee. There are a signi®cant num-
Re¯ective practice77 is frequently cited in health care ber of empirical studies purporting to identify the effects
literature and various authors78±82 argue that re¯ection of supervision on trainees, clients or both.
has a central place in supervision in order to examine
any experience to identify its essential features. How-
Medicine: empirical studies of effects of supervision
ever, Fowler83 cautions that total reliance on re¯ection
on patients
may not always be appropriate in supervision because
beginners need direction. There is quantitative evidence that supervision can have
Juhnke84 advocates solution-focused supervision for an effect on patient outcome. Review evidence86 sug-
3 novice counselling students using a self-report ques- gests that increased deaths are associated with less
tionnaire and initial supervision meetings to establish supervision of junior doctors in surgery, anaesthesia,
their repertoire of skills, and identify speci®c goals. trauma and emergencies, obstetrics and paediatrics.
Sessions are used for the supervisee to identify their Therefore patient care suffers when trainees are unsu-
successful intervention behaviours and decide how to pervised even though some trainees claim to bene®t
continue using and developing these behaviours. from the experience that lack of supervision gives them.
Laker85 uses three empirically determined principles of Furthermore, unsupervised experience can lead to the
effective teaching (academic learning time, response acceptance of lower standards of care because the
presentation and performance feedback) as the basis for trainee may not learn correct practice without appro-
feedback to student teachers, together with comments priate supervision.
on their class management and encouraging them to In the USA, strong evidence for the importance of
re¯ect on practice. direct supervision was obtained by comparing physi-
A summary is presented in Table 4. cians' own ®ndings about patients with ratings of their
residents' reports and history taking, assessment of
severity of the patients' illness, diagnoses, treatment
Effective supervision
and follow up plan.87 When physicians themselves saw
The ultimate purpose of supervision, whether stated or the patients their assessments of the residents were
implied, is to improve patient/client care/experience. more critical. Patients were seen as more seriously ill,
Therefore, improvements in outcomes for patients/ there were frequent changes in diagnosis and manage-
clients are one major test of effective supervision. ment and physicians rated seeing the patient themselves
However, demonstrating that a particular supervisory as very valuable. There were some acknowledged
intervention has a direct effect on the patient/client is weaknesses in the study design (it was not a randomized
extraordinarily dif®cult because of the multitude of trial, and changes in treatment were often minor).
other variables that could have an effect. Consequently, The effects of supervision on quality of care was
some researchers have attempted to side-step this cause/ examined in ®ve Harvard teaching hospitals.88

Table 4 Availability, structure and content of supervision ± summary

There are wide variations in the frequency and amount of supervision for medical trainees in the UK. Where guidelines exist they are
not always met.
Problems with the extent and availability of supervision have been identi®ed across professions.
The learning environment is important.
Supervision can occur `on the job', usually while a practical task is being carried out; informally; in a one-to-one meeting; in peer
supervision; in group supervision; and in networking.
Feedback has been found to be very important for trainees.
Most authors agree that;
Supervision should be structured; supervision contracts can be useful and should include detail about frequency, duration and content
of supervision; appraisal and assessment and objectives.
The content of supervision meetings should be agreed and learning objectives determined at the beginning of the supervisory
relationship.
Supervision should include clinical management; teaching and research; management and administration; pastoral care; interpersonal
skills; personal development; re¯ection.
There is little research into the quality of supervision and its content.

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832 Effective supervision in clinical practice settings · S M Kilminster & B C Jolly

Residents' compliance with process-of-care guidelines Teaching

(assessed by record review), patients' satisfaction and Targeted observation of teaching and provision of feed-
patients' reported problems with care were measured. back resulted in improved teaching skills and increased
Over a 7-month period all 3667 patients presenting quality and quantity of interactions with pupils.92
4 with abdominal pain, asthma/COPD, chest pain, hand
laceration, head trauma and vaginal bleeding were Psychotherapy
included; residents were unaware of the purpose of the A literature review93 found evidence of the effectiveness
study. All patients were given a questionnaire to com- of supervision, including evidence that the quality of
plete on site and some were randomly selected for a supervision relationships effects outcome evaluations.
10-day follow up interview. Analyses were adjusted for Psychotherapy clients (237) self-rated improvement
case mix, degree of urgency and chief complaints. was signi®cantly greater when the supervisor and
Bene®ts of direct supervision applied regardless of the supervisee (i.e. the client's psychotherapist) theoretical
level of resident training and urgency of case. The orientations were congruent.94
authors acknowledge limits to the generalizability of the
study because the ®ve hospitals lacked emergency
Empirical studies of the effectiveness of supervision
medicine training programmes, there may be between-
on trainees/supervisees
hospital variations in quality and frequency of supervi-
sion; patients were not randomized to different groups Most studies examining supervision from the trainees'
and there was no control for the speciality of the perspective use self reports, some also include the
attending physician. supervisors perspective. Although their methodology is
In the trauma service in one hospital, faculty not particularly robust,95 there are areas of congruence
involvement was investigated, over a 12-month period, that indicate some ways in which supervision can be
for surgical procedures and all resuscitations.89 Faculty effective. One methodological problem is that although
involvement was ranked on a ®ve-point scale and data trainees report satisfaction, it might not affect their
were matched to outcomes of death or complications performance or be due to good supervision. Further-
reported in the weekly departmental complications more, student and supervisor emphases can be differ-
conference. Results suggested that supervision had a ent.96 This problem was addressed39 by asking trainee
greater impact where the supervisee/trainee was less clinical psychologists who bene®ted from particular
experienced. The authors concluded that close super- supervision incidents ± the trainee, or the client, or the
vision of general surgical residents during rotations to trainee and client or someone else.
subspecialties is important and that effects of supervi- Residents who were more closely supervised (by
sion can be evaluated by using probability of trauma being directly observed and observing their physician
survival data. They also argue that there is a need to more) during continuity clinic experience, gained
establish measurable standards of supervision. primary-care skills more rapidly than those who were
supervised by reporting back to the physician.97 There
is little work relating to the trainees' behaviour in
Other professions: empirical studies of effects
supervision. Medical students have strategies to appear
on clients
as competent as possible which can con¯ict with
Social work opportunities to learn98 because they `perceived one-
Social workers' effectiveness and the effects of super- to-one consultations as problematic and risky situations
vision on client outcomes were investigated in two in which they struggled for a balance between the
geographically separate teams.90 Cases were classi®ed opportunity to learn and the needs to perform in and
as `risk', `service delivery' or `advice' and outcomes as manage the consultation process'99 (p. 587).
resolved, partially resolved or not resolved. Results There is compelling evidence that postgraduate
demonstrated that client outcomes varied according trainees engage in similar behaviours.100 Clearly some
to the social workers' experience/quali®cations and defensive behaviours are likely to have a negative effect
supervision; more risk cases were resolved with addi- on the supervision process.
tional supervision than without and that less quali®ed There is evidence from literature reviews that
social workers favour `middle ground' decisions. supervisors can affect trainees ± in counselling and
A similar study found that client focused supervision psychotherapy;101 102 in teaching;103,104 in nursing;105
`appeared to increase staff use of basic communication, and in clinical psychology.106 Nursing preceptors had
problem-solving and relationship skills and to improve more skills apparent at higher academic levels of
client outcomes'91 (p. 512). training.107,108

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Effective supervision in clinical practice settings · S M Kilminster & B C Jolly 833

Giving teachers focused feedback resulted in an Trainee ratings of the effects of supervision depend
immediate increase in levels of performance and on its perceived quality;114 the amount of supervision
motivational feedback given to pupils,92 however, social workers received was signi®cantly correlated with
these effects seem to dissipate very quickly. Effects of their satisfaction with supervision.115
self supervision (student teachers scored videotapes of The supervisory relationship `was a better (if not
their classes) were compared with collaborative signi®cantly better) predictor of client outcomes than
supervision; the collaborative model helped students supervisory skills or helpfulness'116 (p. 71).There are
increase the number of positive, speci®c interactions similar ®ndings across professions.14,24,117±120 The
that they had with their pupils but self assessment had section is summarized in Table 5.
little effect.109 Five factors that facilitated change in
the supervised teacher's thinking and behaviour were
Skills and qualities of effective supervisors
identi®ed using case studies.110 The factors were:
developing a collegial relationship; teachers controlled Effective supervisors give their supervisees: responsi-
the products of supervision; continuity over time bilities for patient care; opportunities to carry out pro-
establishing a relationship; using supervisor's obser- cedures; opportunities to review patients; involvement
vations to provide focused data for re¯ection; and in patient care; direction and constructive feedback.121
re¯ection. Most impetus for change occurred when In the UK, the PRHO supervisor needs basic teaching
actual events confounded the teachers' thinking/ skills, facilitation skills, negotiation and assertiveness
understanding. Behavioural changes appeared relatively skills, counselling and appraisal skills, mentoring skills,
early but changes in thinking took longer. Similarly in knowledge of learning resources and certi®cation
psychotherapy, training skills were acquired fairly requirements.122, 123
quickly, but the ability to make treatment decisions Involving residents, giving them responsibility and
and conceptualize cases developed more slowly and opportunity to carry out procedures are the most
required supervision.101 important aspects of the supervisors' role.124 During
Provision of advice, acting as a role model and their residency supervisors became seen more as
feedback was crucial to effective clinical psychology colleagues and residents considered they became more
supervision and differentiated it from ineffective self directed. Radiography students considered the
supervision.111 `Excellent' psychotherapy supervi- most important supervisor characteristics to be the
sors112 let students `tell the story', encouraged them supervisors' teaching skills and techniques, their inter-
to understand the patient, partly by using speculation personal style and professional competence.125
and used fewer technical words. Trainee-identi®ed There is agreement across schools of thought in
gains from supervision include ± strengthened con- counselling and psychotherapy about what constitutes
®dence, re®ned professional identity, increased ther- good and bad practice.126 Effective supervisors have
apeutic perception, increased ability to conceptualize empathy, offer support, ¯exibility, instruction, know-
and intervene, positive anticipation, strengthened ledge, interest in supervision, good tracking of super-
supervisory alliance;113 receiving constructive feed- visees, and are interpretative, respectful, focused and
back, recognizing personal issues and feeling valued practical.127 128 Ineffective supervisory behaviours
and respected.68 include

Table 5 Effective supervision ± summary

There is evidence that

Supervision has a positive effect on patient outcome and that lack of supervision is harmful to patients.
Direct supervision can effect positively patient outcome and trainee development, particularly when combined with focused feedback.
It seems to help trainees gain skills more rapidly.
Supervision has more effect when the trainee is less experienced; more complex cases may need more supervision.
Self supervision is not effective; input from a supervisor is required.
The quality of the supervisory relationship is extremely important. Especially important are continuity over time, supervisees control
products of supervision (supervision may only be effective when this is the case) and that there is some re¯ection by both participants.
Trainees may try to manipulate the supervision process in ways which con¯ict with opportunities to learn and that may not be bene®cial
to patients.
Behavioural changes can occur relatively quickly as a result of supervision whereas changes in thinking and attitude take longer. This
is particularly important where there are relatively frequent changes of supervisor.
Trainees are able to identify many gains from supervision.

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834 Effective supervision in clinical practice settings · S M Kilminster & B C Jolly

`Rigidity, low empathy, low support, failure to con- esteem, their relationship with the intern and to use the
sistently track supervisee concerns, failure to teach or principles of active learning.149 Consequently, they
instruct, being indirect and intolerant, being closed, tended to use covert strategies to correct the interns,
lacking respect for differences, being noncollegial, sometimes they would reframe questions so that the
lacking in praise and encouragement, being sexist, wrong answer became correct or they treated wrong
and emphasising evaluation, weakness and de®cien- answers as possible but needing further thought. The
cies.'128 (p. 168) resultant lack of direct feedback could mean that the
learner remains unaware of errors and their weaknesses.
Helpful supervision events, rated both by supervisors
A summary of this section is presented in Table 6.
and supervisees, include direct guidance on clinical work
(trainees found it more helpful if they were encouraged to
give their opinion early); joint problem solving; reassur- Supervisor training and its effectiveness
ance (not commonly given) and theory practice link- Training for supervisors is valuable and necessary
ing.129 Unusually, these supervisors consistently rated because of changes in professional education.125,150±153
feedback as more important than trainees who found Some authors argue that the supervisees need train-
directive supervision unhelpful. Supervisor trainers ing154 or a daily `training menu'.155 Training is usually
identi®ed provision of advice, providing a role model and evaluated by self report/course evaluations rather than
feedback as crucial to effective supervision.111 by effects on patent/client care.
Empirical studies of the characteristics of effective Supervisor training courses are often not empirically
clinical teachers have relevance to the skills of super- or theoretically based. There are some training courses
visors.130±133 Such studies usually implicitly de®ne that are based on assessment of educational supervi-
effective teaching on the basis of positive ratings from sors' needs.122 Nursing, social work and teaching
students/trainees and/or peers.134 Good or effective literature includes course descriptions emphasising
clinical teachers need knowledge of medicine and understanding ± the concept and purposes of supervi-
patients (which confers clinical credibility); context; sion; trainee's training; structure and types of supervi-
learners; general principles of teaching including the sion including use of supervision contracts; giving and
importance of feedback and evaluation; case based receiving criticism; counselling skills and interpersonal
teaching scripts.135±140 Good/bad clinical teachers are dynamics.126,156±163
differentiated as to encouraging communication Some criteria for supervisors have been established;
between teacher and student; appearing to enjoy in one hospital nurses are only accepted for training if
teaching; being well organized; being a positive role they can demonstrate (by self assessment and manag-
model; facilitating learning and availability.141 More er's evaluation) they have appropriate teaching and
generally, a teachers' interpersonal behaviours, plan- interpersonal skills and professional knowledge and
ning and preparation and the ability to run a session attitudes.164 Future psychiatry consultants may need
well are key factors in good teaching.142 Residents' suf®cient continuing professional development (CPD)
ratings of facilitatory behaviours such as regard, points to qualify as an educational supervisor.74
empathy and congruence were signi®cantly correlated
with their ratings of the learning value of the rotation.143
Evaluation of training
Consideration needs to be given to the use of par-
ticular supervisory strategies.22,138,144±148 Supervisors Changes in supervisors' behaviour, as assessed by
were concerned to preserve interns' self-con®dence and themselves and their trainees were demonstrated in

Table 6 Skills and qualities of effective supervisors ± summary

Empirical and review evidence indicates that

Supervisors need to be clinically competent and knowledgeable; to have good teaching and interpersonal skills.
The relationship between the supervisor and trainee changes as they gain experience.
Helpful supervisory behaviours include giving direct guidance on clinical work, linking theory and practice, joint problem solving and
offering feedback, reassurance and role models.
Trainees need clear feedback about their errors, corrections must be conveyed unambiguously so that trainees are aware of mistakes and
any weaknesses they may have.
Ineffective supervisory behaviours include rigidity; low empathy; failure to offer support; failure to follow the supervisees concerns; not
teaching; being indirect and intolerant and emphasising evaluation and negative aspects.
Assessment of supervisors' skills and selection of supervisors are not addressed.

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 Effective supervision in clinical practice settings · S M Kilminster & B C Jolly 835

speech-language pathology and audiology.165 Supervi- class and sexuality, also confers relative power. Issues
sors received 10 hours of training over 8 weeks which around the operation of racism, sexism and heterosex-
was intended to increase the use of indirect supervisory ism and homophobia are well documented; speci®cally
behaviours. Previous research had demonstrated the there is extensive evidence demonstrating the relatively
importance of indirect styles and found that inexperi- subordinate positions of women and black people
ence leads to a more direct style. Indirect, direct and throughout the professions at all levels. It is therefore
preparatory supervisory behaviours were rated before reasonable to assume that these issues could affect the
and after training. Supervisors and trainees rated supervisory relationship.
supervisors as using more indirect behaviours after A number of studies have demonstrated or argued
training. that mentoring (by someone from a similar back-
The Norwegian Medical Association offered an ground) is an effective way of providing role models and
extensive training programme to senior hospital con- support for black people, women and non-traditional
sultants because of changes in specialist training.166 students.175±179 Matching is an important issue in
This was evaluated in two postal surveys. The training mentioning and there is a need for further research on
had affected motivation, increased awareness about matching of personal and social characteristics.119, 180
learning need and increased interpersonal and com- Arguments are made from personal and theoretical
munication skills; institutional support of the process perspectives that gender dynamics affect counselling
had been vital. and social work supervision.181±183 Quantitative studies
Table 7 summarizes this section. on the effects of gender are inconclusive.184, 185
Supervisors need to understand issues of power and
social strati®cation including institutional racism;186
Other supervision themes
there are some training programmes intended to address
aspects of multicultural working.187, 188 Transcultural
Time
relationships can have transforming effects189 but there is
There are consistent reports of dif®culties in ®nding also a need for culturally sensitive supervision.190
time for supervision. However, time taken in supervi- Long191 and Russell and Greenhouse192 discuss
sion may be counterbalanced by more effective work- some of the issues raised by heterosexism and homo-
ing;167±169 residents ordered more tests when they were phobia in counselling and psychotherapy supervision.
less supervised.170 Planning and time-management
strategies can help more effective and ef®cient clinical
Conclusion
teaching.171, 172 Extra time needed for students has
been costed173 and optimal staff/student ratios in out- The evidence generated from this review has been
6 patients departments examined.174 summarized at the end of each section. It only partially
answers our original questions and suggests others. The
quality of supervision relationship is probably the single
Race, gender and sexuality
most important factor for the effectiveness of supervi-
Supervision is a context-bound activity like any other. sion, more important than the supervisory methods
Most supervisory relationships have a de facto power used. Feedback is an essential component of supervi-
relationship between the supervisor and trainee. Indi- sion and must be clear so that the trainee is aware of
vidual social position, particularly race, gender, social their strengths and weaknesses. It is important that
the trainee has some control over and input into
the supervisory process. Finding suf®cient time for
Table 7 Supervisor training and its effectiveness ± summary

The need for training is widely accepted and there is some

Table 8 Potential research questions
evidence that it can be effective.
Training probably needs to include at least some of the following:
understanding teaching; assessment; counselling skills; In what circumstances is supervision necessary?
appraisal; feedback; careers advice; interpersonal skills and What sort of supervision should this be?
understanding the concept and purposes of supervision. What is the optimal length and frequency for supervision?
There may be a need for criteria for entry into or satisfactory How can the quality of the content of supervision be ensured and
completion of supervisor training courses. developed?
There is some evidence that training can have a positive effect How can effective supervision be assessed?
on supervisors. What additional training do supervisors need?

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836 Effective supervision in clinical practice settings · S M Kilminster & B C Jolly

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supervision meetings than `on the job' supervision and
Nurs Times 1994;90 (39):35±9.
work-based learning although there are some studies
7 Bishop V. Clinical supervision questionnaire results.
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Nurs Times 1994;90 (48):40±2.
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