General practice supervisors play an integral role in training future general practitioners (GPs), with supportive supervision identified as fundamental to registrar training experience.1,2 Supervisors undertake a complex set of roles, and negotiate multiple duties of care to themselves, their patients, their registrars and their profession.3–5 A recent survey predicts significant attrition of supervisors over the next five years.6 If we wish to engage, retain and support supervisors, it is important to know what enables and hinders them in their work. This requires understanding what contributes to GPs adopting a supervisor identity.
Becoming a supervisor necessitates an expansion of professional identity from clinician to clinician and supervisor. Professional identity formation (PIF) is important in medical education7–9 and has been described as ‘the cornerstone of professionalism’.8 PIF involves development of professional values, moral principles, behaviour, aspirations and engagement in ongoing self-reflection.8,10 The way multiple identities are conceptualised and managed has implications for the education of clinicians.9 Further, the way supervisors manage their own professional identity impacts on their registrars’ PIF.11
Wenger’s ‘community of practice’ (CoP) framework views PIF occurring in the context of participation in the workplace, belonging to its working community and interacting with others in the same profession.12 This framework provides a useful lens for understanding PIF in the general practice postgraduate setting, where learning and professional development occur through immersion in the communities of training practices and Regional Training Organisations (RTOs).
While there is a body of work that describes the qualities, skills and educational practices of general practice supervisors,13–17 very little examines PIF of general practice supervisors. Knowing what contributes to the development of a general practice supervisor identity is important to inform effective training and support of supervisors by RTOs, training practices, colleges and funding bodies.
Therefore we ask, what factors contribute to the PIF of GP-supervisors?
Methods
This study took a descriptive and interpretive qualitative approach that enabled in-depth exploration of supervisors’ experiences. Supervisors were selected from an RTO based in Victoria, Australia with purposive sampling18,19 to recruit general practice supervisors with diverse characteristics, contexts and years of experience. Appraisal of information power guided sample size.20
Semi-structured interviews were conducted by BG (n = 11) and CK (n = 4) between May and September 2017. Interviews explored:
- background as a general practice supervisor
- experience being a GP and a supervisor
- meaningful experiences
- relationships that are significant in the general practice supervisor role
- things that helped or hindered supervisor professional development
- thoughts about the future
- support from the RTO (what helped and/or hindered, suggestions for improvement).
Interviews were guided by our questions and by constructs from Wenger’s theoretical framework. They were undertaken face to face (n = 11), by phone (n = 3) and videoconference (n = 1), and ranged 31–78 minutes (average 46 minutes).
All data were digitally audio-recorded, transcribed verbatim, and de-identified. Data were managed using NVivo 11. We used template analysis21 and developed our framework through a process of interrogating the data according to our research questions and using the lens of Wenger’s CoP framework.12 Our categories were derived both inductively and from those of Wenger’s constructs that resonated with the data. These constructs are detailed in Box 1.
| Box 1. Wenger’s12 community of practice constructs |
Community of practice (CoP)
A group of people who share a concern or passion for something that they do and learn how to do it better as they interact regularly.
Identity as nexus of multi-membership
‘We define who we are by the ways we reconcile our various forms of membership into one identity.’12 Membership in any CoP forms only one part of our identity. Individuals belong to many CoPs, with some more central to their identity than others. Multiple parts of an identity cannot be simply turned on or off; rather, they co-exist. These identity parts may include being a clinician, a supervisor, a parent, a small business owner. Reconciling different forms of membership involves finding ways for the multiple parts of our identity to coexist. This may be a constant challenge.
Developing a regime of competence
Membership within a CoP is achieved by developing a ‘regime of competence’ that includes knowing how to engage with others in the community, being accountable, understanding what matters in that community and making use of the repertoire of that community. A repertoire of a community includes its routines, tools and language. In general practice supervision, this incorporates the repertoire of both GP clinical practice and of supervisory practice. Fluency in the language of the general practice supervisory community is an important indicator of belonging to the community. Learning from the talk of the community is important for developing the identity of a community member.
Belonging and membership
Mutual engagement is key to belonging and membership in a CoP, and involves participation and accountability. Mutual engagement needs to be meaningful to the participants and thus influences how individuals view the world. Hence being a supervisor will give an individual a particular focus, and will influence their interpretations, choices and what they value.
Ownership of meaning
Owning the meaning for what we do in a role is important for identity formation. Meaning is derived through participation within a community and from our ideas about who we are based on our experiences of participation. |
BG led the analysis and co-authors contributed to analysis and interpretation. Regular partial-team (BG and JB) and whole-team meetings enriched the analysis and enhanced interpretative rigour.18 Three researchers held positions within the supervisors’ RTO. DN was external to the organisation. Interviewers BG and CK did not have a prior relationship with the participants. Through the research process we considered the influence of our roles on our data collection, analysis and reporting.
Ethics approval was granted by Monash University Human Research Ethics Committee (Project No. 7994).
Results
Analysis was undertaken with data from 15 participants (Table 1), with experience as a GP ranging two years to 42 years (median 25 years).
| Table 1. Characteristics of participating general practice supervisors |
| Years as general practice supervisor |
Sex |
Practice location |
Total |
| |
Female |
Male |
Metropolitan |
Rural |
|
| 1–2 |
2 |
2 |
2 |
2 |
4 |
| 3–7 |
2 |
3 |
3 |
2 |
5 |
| ≥20 |
2 |
4 |
2 |
4 |
6 |
| Total |
6 |
9 |
7 |
8 |
15 |
Four interdependent themes in the development of a supervisor identity were identified:
- Learning the skills of being a supervisor
- Belonging in the role of supervisor
- Finding meaning in supervision
- Balancing the role of supervisor and clinician.
These themes were identified as we found congruence between our theoretical framework and the data.
1. Learning the skills of being a supervisor
Supervisors learned supervisory skills over time. These included: managing with their registrar ad hoc encounters, formal teaching sessions and giving feedback. Managing ad hoc encounters was particularly challenging for supervisors, and an important skill to learn early. This meant learning to manage unpredictable interruptions often involving transitioning from attending a patient to attending to the registrar with their patient. This was described as ‘switching on and switching off’, ‘gymnastics of the mind’ and that ‘your head can literally be spinning’:
… you would need to interrupt your own consultation and go and, and take on this whole bunch of new information in a short space of time and, and still try and guide someone to make their own decision. (S15, 1–2 years as supervisor)
Supervisors developed strategies to minimise the impact of disruptions to their clinical work by streamlining the way registrars sought guidance. This developed over time and with experience. Strategies included leaving catch-up spaces, using internal messaging and teaching the registrar when and how to seek help:
… these sorts of things now are discussed right in the first week […] you set the parameters very clearly, and the registrar’s got some guidance on how to get your attention and what do if they’ve got a question, which questions can wait ’til the teaching session. All of that helps to plan your day and you don’t get as bombarded. (S14, ≥20 years)
Over time, supervisors developed a mindset that normalised, accepted and saw value in registrar interruptions throughout the day:
… an interruption is not an interruption when you’re a registrar supervisor. It’s part of the job, and it’s to be welcomed, because it’s an opportunity to talk about something when it’s red hot. (S1, ≥20 years)
When developing skills for conducting formal teaching sessions, supervisors moved from more didactic teaching sessions to case-based or conversational sessions:
… realising that you actually know a lot and you don’t have to write it down, you don’t have to have a slide show or anything like that. There’s a lot of things that you can talk about and discuss, really off the cuff ... (S3, 3–7 years)
Increasing competence in giving feedback was attributed to reflecting on experiences of giving feedback and RTO-led supervisor professional development workshops:
I said it to the [registrar] [in what] I thought would be quite a casual manner […] but I found that he took it quite seriously. His facial expression just changed […] maybe I need to try different strategies to that next time. (S12, 1–2 years)
… the program has been relentless in making us aware of the value of feedback to the registrars […] So I think I have improved […] I’m certainly a lot better than I was. I feel more confident giving feedback, and more structure […] I just think it’s been helpful that it’s always on the agenda. It’s always up there as a priority, always putting it front of mind. (S5, ≥20 years)
Supervisors consolidated skills through conversations with other supervisors. Their sense of identity as a supervisor grew with increasing competency
and confidence.
2. Belonging in the role of supervisor
Meaningful interactions with others in the role of supervisor was important for identity formation. This involved interaction with the registrar, training practice, RTO support staff and medical educators, and other supervisors.
Regular interaction with the registrar was fundamental. It provided the means for engaging in the supervisor role and for receiving acknowledgement of themselves as supervisors by their registrar. Being trusted by their registrar was particularly affirming:
I had a registrar who came to […] talk to me about a problem he’d had the night before […] he was really open and I’m glad he came to me. (S6, 3–7 years)
Interactions within the training practice were important. When supervisors felt supported by the training practice, they felt valued and enabled as supervisors:
… teamwork. Really, everyone in the clinic is important […] to support me to be a good supervisor. (S9, 1–2 years)
… you need a relationship with your own practice manager and staff and colleagues, ’cos they’ll help sort of inform you of things that are going on with the registrar. (S8, ≥20 years)
Simply making time for a teaching session, initially, was quite hard […] However, the staff came to the party and sorted me out. (S13, 3–7 years)
Interaction with RTO staff was important for validation and support:
… [the medical educators who come to do external clinical teaching visits] make me feel like at least I’m on the right [track] in terms of where I think the registrar should be at, and where they think the registrar should be at […] that validation is actually quite useful. (S15, 1–2 years)
RTO-supported supervisor workshops were important for developing supervision skills and connecting with other supervisors. Meeting with colleagues was a powerful driver for engaging in the role through sharing ideas and experiences. These interactions were important for strengthening supervisor identity, given the relative day-to-day isolation experienced by some:
… it helps make you feel part of a teaching team. You are part of a group of other like-minded GPs who are interested in dedicating to teaching others. So, when you’re sitting in your little silo in your practice, you don’t get that exposure, you just feel like you’re one person, or maybe two, doing your little thing with this little person. But this helps you get the bigger perspective. (S14, ≥20 years)
Interaction with other supervisors was important for nurturing commitment and a sense of belonging, particularly for new supervisors who were able to benchmark what they were doing with experienced supervisors:
… the networking opportunity, just being able to talk to the other supervisors in an informal setting and figure out what they’re doing, and what their practices are like and what their experiences are like, kind of allows you to understand what it looks like to be a supervisor going down the track. (S15, 1–2 years)
3. Finding meaning in supervision
Wenger ascertains ‘making meaning’ as an important dynamic in developing identity.12 Participants found meaning in the supervisor role by feeling valued by the registrar and the RTO; perceiving benefits to having a learner in the practice; contributing to general practice and to the wider community; and satisfaction derived from teaching.
Feeling valued by the registrar was important:
… getting nice feedback from your registrars […] when [the registrar] left her term here, she just said, ‘Oh, you’ve just been such a wonderful role model for me’, which was a lovely thing. (S11, ≥20 years)
I don’t think the registrars acknowledge the generosity of the practices in allowing them to come in and train in their organisation. I don’t think there’s any sense of that at all […] that’s a big disappointment. (S5, 20+ years)
Acknowledgement by the RTO was important and, conversely, lack of appreciation had an impact. This was particularly expressed around issues
of remuneration:
I really think supervisors should be a little bit better remunerated for their work, because I think you actually do suffer financially if you decide to do the job and do it properly. And I don’t see why that should be the case. […] And, also I suppose the recognition is kind of nice, that you’ve got an important part to play in, in medical education. And sometimes it’s a little kind of underwhelming. (S14, ≥20 years)
Supervision was perceived as meaningful in the benefit it provided personally, and to the practice:
I’m much more effective as a GP with the exposure I get to all the learners … it teaches so much about yourself and different ways of approaching things […] hosting learners has made me a much better GP than I would have been (S7, ≥20 years)
… one of the most wonderful things for our practice is that we have such a fantastic group of doctors here. And that’s basically because nearly all of them are ex-registrars (S11, 20+ years)
Contributing to the development of registrars and ‘watching them mature as doctors’ was meaningful:
… improving the capacity of the registrar that was underperforming […] to actually see it play out in practice was quite rewarding. (S5, ≥20 years)
Satisfaction in teaching was coupled with contributing to the future GP workforce and the community:
I have a serious responsibility to try and ensure that the communities like this will have GPs … with extended skills, who want to work and provide services […] that’s one of my drivers in being a supervisor. (S7, ≥20 years)
… give back something of my experience, you know. Why waste it? I think experienced GPs should be helping the younger generation and passing on that knowledge … (S10, 1–2 years)
4. Balancing the role of supervisor and clinician
Supervisors viewed their clinician role as central to their identity.
I would certainly see my main role as a GP, and in addition to that, I also supervise and educate registrars […] seeing the patients is still the primary part of it. (S11, 20+ years)
Although the roles of supervisor and clinician were seen mostly as complementary, sometimes they were in tension.
They’re not separated at all. They’re totally integrated. (S1, ≥20 years)
It’s just a case of dovetailing in your normal clinical load with the registrar and their needs […] sometimes it can be pretty difficult and quite stressful […] I suppose 90 per cent of the time it seems quite, quite manageable […] But there still are times when, particularly at the beginning of the term, when the registrar needs a lot more kind of input … that can be … a little bit more unpleasant. (S14, ≥20 years)
Supervisors’ ability to balance the two roles developed over time. Managing multiple roles with increased workload, time pressures and complexity was challenging.
Probably the time constraint is the biggest thing […] just that difficulty of having an already busy job and finding time to do it as well as I’d like. (S8, ≥20 years)
Being both the registrar’s supervisor and employer could be difficult.
… obviously you are their employer […] That dynamic can sometimes be difficult when a registrar either … is not playing ball and complaining about their pay or some other issue. And then to try to establish as sort of a nurturing relationship with a registrar so that they feel comfortable to come and ask you questions and not terrified, to try to create a positive atmosphere that they would enjoy their term, ’cos on a personal level, you want to try to get on with them. (S14, ≥20 years)
Patient acceptance of the GP and practice’s teaching responsibilities facilitated supervisors’ reconciliation of clinical and supervisory roles. This was characterised by patients being willing to attend registrars and have the registrar seek advice from their supervisor.
I do think that [patients] respect that you actually take that job on of teaching. So, it actually brings you, yeah, more respect rather than less. They don’t get annoyed, I mean, maybe they do get annoyed, but they don’t tell me, if I rush off and do something. (S6, 3–7 years)
Discussion
Our study provides new insights into the PIF of general practice supervisors in Australia. By drawing on the CoP framework12 our study highlighted four interdependent factors that are important for supervisor identity formation: learning the skills of being a supervisor; belonging in the role of supervisor; finding meaning in supervision; and balancing the role of supervisor and clinician.
Participants typically viewed their multiple identities in a hierarchical fashion, with activities related to their clinical identity taking precedence.22 Many viewed being a GP and a supervisor as complementary,23,24 with supervisors establishing a sense of balance between their roles over time.22 As GPs incorporated supervision into their daily clinical work, the two roles became more synchronous. Many reported being a supervisor made them a better GP, concurring with previous reports highlighting the reciprocal trainee–supervisor learning relationship.1,3,6,25
In line with other research,26,27 supervisors experienced tension between competing demands of clinical work and supervision as they found themselves being accountable for their own patients, their registrar and the registrar’s patients. Managing unpredictable ad hoc interruptions from their registrar was a particular skill to acquire. Other studies have reported this complex negotiation of conflicting agendas in managing ad hoc supervisory encounters.28 These interruptions became easier over time, as supervisors developed strategies and a mindset that normalised and valued registrar requests for help.
Knowing what contributes to the PIF of a general practice supervisor informs effective training and support. Our findings highlight the important role of training practices, RTOs and funding bodies in facilitating the PIF of supervisors and affirming their place within their CoP.
Training practices can provide an environment that respects the supervisor role and has the structures to enable the supervisor to undertake their task. This requires committing time and resources to support an effective supervisory relationship which is necessary for affirming the supervisor identity and for providing the opportunities to develop supervisory skills.16,29
RTOs can support supervisors’ PIF in several ways, including providing support and advice to supervisors at the time it is needed, having adequate acknowledgement of the supervisory role, providing ways for supervisors to learn the required skills, and providing interactive professional development opportunities. Face-to-face meetings with other supervisors provide collegial support and are a powerful driver for stimulating engagement in the role through the sharing of ideas, uncertainties and experiences. Our findings highlight the strong value of face-to-face interaction and affirms the need for continued funding and resourcing of activities that afford supervisors the opportunity to meet with one another.
Finally, our findings suggest that while supervisors are dedicated, motivated and take great satisfaction from seeing their registrars successfully progress through training, inadequate recognition and remuneration remains a tension, undermining the value of their key role in general practice training.1,6,25 Recognition for the value of supervisors and the time impost of supervision requires adequate remuneration.
Limitations
Using CoP as a sensitising lens for analysis meant we focused on the relational aspects of the supervisory role. Taking an individualistic approach may generate other insights. Our sample was drawn from one RTO and depended on the supervisor being willing to be interviewed. Whether our findings can be translated to other contexts will need to be judged by the reader familiar with those contexts. We did not examine the perspectives of those who have left general practice supervision; this was beyond the scope of our study.
Conclusion
Development of a supervisor identity is strongly tied to relationships that support and reinforce the role of supervisor. These include a supervisor’s relationships with their registrar, their practice community, the training program staff and educators, and with a community of supervisors. As general practice vocational training evolves, it will be important to adequately recognise, protect and cultivate a program that values these relationships and remunerates supervisors who are at the frontline training the GPs of tomorrow.
Implications for general practice
Given the integral role of supervisors in general practice vocational training, and the complexity and demanding nature of this role, it is essential to understand what is involved in developing a supervisor’s identity to inform effective training and support. Our study provides new insights to the PIF of supervisors in the Australian context. These findings highlight the important role training practices and RTOs have in supporting supervisors. This is to provide skilling, support and remuneration to establish an environment that respects the supervisor role, and provide structures that enable the supervisor to undertake their task. Our findings also reinforce the need for supervisors to have adequate recognition and remuneration that reflects the time and cost impost of supervision. Finally, developing and supporting supervisor networks is a high priority; there is a need for continued funding and resourcing of activities that afford supervisors the opportunity to meet with one another.