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Thursday, January 13, 2011

Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety



Have you ever stopped and wondered what good clinical supervision means? Supervision is one of those concepts in academics that we are expected to do with little, if any, guidance. Many factors within medicine have led to an increase in the expected levels of supervision recently. Work hours restrictions, Medicare rules, and a call to arms about patient safety have prompted calls for more and better supervision. The problem is, "What is appropriate clinical supervision?" This article took a qualitative observational research approach to looking at this exact problem with a goal of defining a conceptual model of clinical supervision.

Methods:

This study uses a qualitative approach referred to as grounded theory methodology. Participants were faculty and teaching teams from the emergency department and general medical floor. To minimize the Hawthorne effect, incomplete disclosure was employed, i.e. the participants knew they were being observed, but they didn't know what was being observed. Observational data were collected and refined over a single calendar year.

Results:

Their analysis revealed that supervisory activities related to patient care are distinct from other types of supervision, such as formal teaching. These activities seem to fall along a continuum from less to more involved.

Routine Oversight: These are activities planned in advance and expected by all involved in the clinical setting. In a sense, routine oversight is simply monitoring the trainees activities. In emergency medicine, this type of oversight is used when hearing case presentations from students or residents followed by probing, refinement, and confirmation of the management plan.

From my perspective, this is the bread and butter supervision that we all do from shift to shift.

Responsive Oversight: In this type of oversight, the direct involvement of the supervisor increases either as a result of a direct request from the trainee or in response to a concerning clinical situation. This can involve repeating history and exam findings, observing trainees in action, or coaching learners at the bedside (i.e. supervising procedures).

Triggers that increase supervisor vigilance often result in responsive oversight. These include:

  • Clinical Cues: unexpected changes in patient conditions, unstable patients
  • Information from a secondary source: family or nursing concerns brought to the supervisor
  • Language Discrepancies: Clinical presentation not matching clinical data (labs, radiology, etc)
I find that this level of supervision varies from learner to learner depending on my trust in the trainees abilities and confidence.

Direct Patient Care: This is the highest level of supervision and often is initiated when the supervisor realizes that the clinical situation has exceeded the learners ability to manage the care of the patient. This may happen quickly, as one would expect when working with medical students, or may happen only in extraordinary situations with senior trainees.

Personally, when working with senior trainees, I find that this becomes more of "Team Management" with the senior assuming control of some tasks while I handle other tasks to manage a critical ill patient.

Backstage Oversight: The final type of oversight occurs with little trainee knowledge. Backstage oversight includes seeing patients independently of the trainees (we do this a LOT in emergency medicine) or reviewing pertinent patient data such as labs or radiology in the absence of learners.

Final thoughts: As a junior faculty member, finding the right balance of supervision to learner autonomy has been a challenge. This article confirms what we probably all do in our day to day clinical practice. It demonstrates that supervision is a fluid process involving an ebb and flow of involvement that is linked to learner and patient factors. Increased awareness of factors that should prompt us to upgrade our level of supervision will benefit our learners and potentially make patient care a little bit safer.


Reference:



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