The Royal College of Psychiatrists stipulates that all psychiatrists in training should receive regular, timetabled, weekly supervision by their trainer. Specialist registrar (SpR) training guidelines (Royal College of Psychiatrists, 1998) do not quantify the time-period. It is specified, however, that senior house officers (SHOs) should have a “protected hour per week” with their educational supervisor (Reference CottrellCottrell, 1999). As supervision is a relatively new requirement, very few trainers will have been supervised — let alone trained in supervision. Informal discussion suggests that the practice of supervision varies widely. It has been emphasised that supervision should be based on the needs of the trainee and, hence, will vary over time, but should be structured with clear aims and objectives (Reference CottrellCottrell, 1999). Cottrell suggests that good supervision should cover the following topics: clinical management, teaching and research, management and pastoral care. However, he points out that it may not be possible for all trainers to offer supervision in each of these areas personally. Previous research (Reference Herriot, Bhui and LelliotHerriot et al 1994; Reference AzuonyeAzuonye, 1997) has found approximately three-quarters of trainees in London received weekly supervision, but that many trainees and trainers were dissatisfied with it.
The aim of the project was, therefore, to find out trainers' and trainees' views about the purpose and content of supervision and the practicalities of current practice. This information could then be used as a basis for suggestions to improve and standardise supervision.
The study
All trainers and trainees on the University College London/North London psychiatry rotation were sent a questionnaire asking about their current supervision practice and experiences. This was devised from literature regarding the purpose and content of supervision (Reference Herriot, Bhui and LelliotHerriot et al, 1994; Reference Robertson and DeanRobertson & Dean, 1997; Royal College of Psychiatrists, 1998; Reference CottrellCottrell, 1999). The questionnaire was piloted and amended as necessary. The final questionnaire began with questions regarding the concepts of supervision and had open questions regarding the ideal content and time spent in supervision. The second part consisted of a list of the possible content of supervision and asked respondents to tick ‘yes’ or ‘no’ for each category (see Table 1). We also asked how long was spent in supervision and there was a space inviting respondents to make comments.
Table 1. Topics covered by existing supervision, according to trainees and trainers
| Trainees (%) n=55 | Trainers of SpRs (%) n=17 | Trainers of SHOs (%) n=40 | |
|---|---|---|---|
| Clinical management | 45 (82) | 15 (88) | 36 (90) |
| Teaching you to teach others | 7 (13) | 11 (65) | 9 (23) |
| Research | 24 (44) | 16 (94) | 20 (50) |
| Management training | 18 (33) | 12 (71) | 10 (25) |
| Working within the multi-disciplinary team | 30 (55) | 15 (88) | 35 (88) |
| Pastoral care | 30 (55) | 11 (65) | 34 (85) |
| Exam practice/case presentations | 28 (51) | 1 (6) | 31 (78) |
| Presentation at meetings | 19 (35) | 5 (29) | 17 (43) |
| Setting learning objectives and priorities | 35 (64) | 11 (65) | 28 (70) |
| Feedback on performance | 34 (62) | 15 (88) | 34 (85) |
| Reviewing case note entries and letters | 37 (67) | 3 (18) | 23 (58) |
| Supervision in report writing | 14 (25) | 11 (65) | 25 (63) |
| Careers guidance | 36 (65) | 13 (76) | 35 (88) |
Initially, we numbered the last page to enable us to identify non-respondents and so gather as complete a data set as possible. This page was then discarded to preserve anonymity. Those who had not returned the questionnaire after the first mailing were sent it once again. The length of time spent in supervision was calculated to give a weekly figure.
Findings
Respondents
The overall response rate was 97/127 (76%). Completed questionnaires were received from 55/75 (73%) trainees and 42/52 (81%) consultants (17 consultants worked with a SpR and 40 consultants worked with an SHO).
Ninety-four of all respondents thought that supervision was a good idea but three did not. The ideal time suggested ranged from 0-300 minutes with a median time of 60 minutes (s.d.=32).
Supervision of trainees
Forty-two (76%) of the trainees received regular, timetabled supervision, three (6%) received none, four (7%) had it timetabled, but in practice rarely received it and three (6%) received it although there was no timetable. The time reported spent in supervision per week by trainees ranged from 30 to 120 minutes (median 60; s.d.=16). Thirty-four (62%) had an agenda for supervision and 16 (21%) did not. Twenty-nine (53%) felt it was based on their needs whereas four (7%) did not.
There was a disparity between trainees' reported experience of supervision and what trainers said they did (see Table 1). These are particularly marked in the areas of teaching, research, management training, working with a multi-disciplinary team, pastoral care, feedback on performance and supervision on report writing. Supervision for SpRs and SHOs was constituted differently. Clinical management was covered in most trainees' supervision at all levels. However, SpRs were more likely to receive supervision in teaching, research and management. SHOs were more likely to receive pastoral care, exam practice and supervision on written work.
Trainees' comments
A consistent theme was the need to plan the time for supervision. Several trainees mentioned that they had not had supervision over a period of years. In addition, many trainees commented that supervision could not be dichotomised into being either useful or not. Instead, it depended on their individual needs at any one time (e.g. if sitting an exam); the demands of the job; and the ability and willingness of the consultant to supervise.
“An hourly scheduled meeting often ends up with nobody knowing how to use it… an hour will be insufficient for some junior psychiatrists but may make the trainer feel they have done their job.”
“It depends on the consultant, my experience has been very variable.”
“A clear lack of training and supervision for supervisors.”
In addition, trainees felt they should take some responsibility for their own supervision.
“It is a flexible arrangement between the trainee and trainer and it takes two to tango.”
Some trainees felt that supervision should take place on a day-to-day basis, for example, at ward rounds and out-patient clinics and in informal settings.
“I think that a lot of supervision can take place on the hoof and sitting down at a specified time doesn't necessarily get more things done.”
“The idea of going for coffee and being a bit more human.”
Other trainees felt that the value of supervision was that it could be individually tailored to their needs. One trainee commented that they wanted an insight into the life of a consultant, rather than the traditional help with their own role.
A few trainees commented on the ability of supervision to build up a personal relationship, “chit-chat, gossip and light-hearted chat”. In contrast, others felt that given the hierarchical nature of the medical profession, personal relationships and pastoral care were impossible.
“Impossible to use supervisor as pastoral carer… you want the boss to think you're efficient, competent and dedicated… unrealistic to express negative feelings about the job… at some point we will ask them for a reference.”
There was an awareness of pressure on consultants' time and on trainees' time: “if consultants don't have the time, they need to be given it”. One trainee had compromised on half an hour a week of supervision because of study leave and clinical commitments.
Supervision by trainers
Of the 17 consultants working with SpRs, 15 (88%) were supervising, one did so sometimes and one did not. Ten (59%) had an agenda for this supervision and two (12%) did not. The length of time spent supervising SpRs ranged from 4-60 minutes per week (median 55, s.d.=25).
Thirty-eight (92%) of the 40 consultants working with SHOs were supervising them. One consultant had supervision timetabled, but other commitments prevented it taking place every week and one consultant did not reply to this question. Twenty-six (65%) had an informal agenda for this, seven (18%) did not and one (3%) did sometimes. The length of supervision ranged from 30-60 minutes per week (median 60, s.d.=12).
Trainers' comments
Many trainers wrote that there was a need to be flexible about supervision and to consider the trainees' level of experience in planning both what to cover in the sessions, and how much time to offer them.
“Definitely for SHOs. SpRs — probably, though not quite as clear there is a need for this to be as frequent.”
“Weekly time will be appropriate for more junior doctors — or for trainees inexperienced in a setting. This can then be reduced to a minimum of once a month.”
Some felt that an hour was an excessive amount of time.
“…protected time is necessary, but an hour can seem excessive.”
“I find it hard to keep going in responsive mode for more than 30-45 minutes.”
Several consultants wrote that supervision should not be divorced from day-to-day work, or confined to a specific time, but should take place during normal duties.
“Learning should be an apprenticeship, that is, the trainee should be with the trainer in different clinical settings, learning by experience, discussion, modelling, etc.”
One commented that trainees were sometimes “less interested in supervision”.
Many consultants found it difficult to find sufficient time in busy schedules to supervise trainees for 1 hour every week, particularly where they have more than one trainee”… but when I have two or more SpRs, an SHO and other trainees it becomes impossible to find 1 hour for each of them”. They were also aware of the time pressures faced by their trainees: “every couple of weeks does seem like plenty when everyone's busy.”
One consultant felt that supervision should include the opportunity for trainees to see what it is like being a consultant and learning strategies to cope with the job.
Discussion
Twenty-four per cent of trainees were not receiving weekly, timetabled supervision. This is consistent with previous research (Reference Herriot, Bhui and LelliotHerriot et al, 1994; Reference AzuonyeAzuonye, 1997), but is surprising, considering it is a College requirement. The content of supervision appeared to be based on clinical matters. Azuonye (Reference Azuonye1997) also found clinical issues dominated supervision time, which some of his respondents described as a continuation of the ward round. This highlights the fact that there is still scope for improvement. For example, the content of supervision could be broadened to include the other important areas of teaching and research, management and pastoral care as suggested by Cottrell (Reference Cottrell1999).
It is unclear why there was a disparity between trainees' and trainers' reports of the content of supervision. It may be that some aspects of supervision are more concrete than others, for example, practice for exams as compared with management training. Trainers and trainees may have different perspectives on what constitutes supervision in each of the specified areas. Creating an agenda for supervision may help clarify this, but less than two-thirds of trainees did this. The difference between the constitution of SpR and SHO supervision may, in part, be related to the trainee's level of experience and hence, their needs. However, it would be expected that other aspects of supervision such as careers guidance, pastoral care and giving feedback on performance would be relevant to all trainees.
Trainees emphasised the need for planning and structure to supervision, but also the value of flexibility. Both trainees and trainers were aware of time constraints. However, the duration of supervision should be based on trainees' needs, rather than dictated by pressure of work. This highlights the fact that supervision is time consuming and this has financial implications. The value of informal supervision was also acknowledged, with some trainees and trainers wanting supervision to take place in the real clinical world. This perhaps links in with the idea that trainees should also have the opportunity to observe their trainer at work in different settings (Reference CottrellCottrell, 1999).
The limitations of this study are, first, that it looks at the practice of supervision across only one rotation and this may differ from others in the country. Second, not everyone completed the questionnaire. However, the anonymity of replies is likely to have encouraged accurate reporting.
Supervision is popular among both trainees and trainers and should be available for all trainees. Trainees would like it to cover more than just clinical management and include topics such as teaching, research, careers guidance and presentations. The content should be organised with clear, but flexible, agendas. Both trainers and trainees should share responsibility for ensuring it takes place. The College should ensure it is provided for all trainees. There may also be a place for offering consultants training in the practice of effective supervision.
Acknowledgements
We would like to thank all the trainees and trainers who completed the questionnaire.
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