Secondary care clinical supervisors’ views on the tensions between education and service delivery in medical student clinical placements

Purpose Increased external scrutiny on medical education has led to a need to ensure that clinical placements are delivering high quality education in an increasingly high pressure environment. Clinical supervisors provide the oversight of education delivered to undergraduate medical students in the clinical environment yet their views are seldom sought. This piece of work seeks to explore their views on the tension between delivery of education and patient care to support the development of placement based education.


Introduction
It is well documented that the National Health Service is working at high intensity and strain. Despite this it remains responsible for the provision of training to many medical, and other allied health professional, students through statutory and contractual links with Health Education England (Health Education England, 2019). The delivery of education in a pressure environment can lead to significant challenges.
Clinical supervisors are working consultants who coordinate the placement for students placed with them. Whilst there may be some financial incentive through sessional payments it is often unrelated to the availability of time within the main working day.
These workplace tensions, and the nature of the supervisor as a non-specialist in education, have implications within the conceptual framework of communities of practice, which extend beyond the community that is the hospital ward or wider healthcare team. It is clear that institutional norms can drive supervisor identity and behaviour and, evidence shows that most clinical teachers are untrained for teaching roles. Within the community of practice that is the clinical team there tends to be role modelling of the senior person in the 'firm' (a term for a medical team) along with a lack of challenge to this perceived norm (Eath et al., 2016). Work from the Netherlands showed clear links between institutions and teaching styles with greater time available to spend in education linked to a more student centred approach to learning (van Luijk et al., 2014).

Methods
This study utilised qualitative research methodology, specifically interpretative phenomenological analysis (IPA). The aim of IPA methodology is to understand how the clinical supervisors make sense of their experience of clinical placements, and how they interpret the notion of 'quality' of placement activity in relation to the tension between service delivery and education. The IPA methodology focusses on subjective lived experience which is what this work is seeking to explore (Hefferon and Gil-Rodriguez, 2011).
An initial literature search was undertaken to establish the current evidence in this area. The findings of the literature review informed the formulation of the semi-structured interview guide utilised in this study.
Ethical approval was granted by the University of Sheffield Ethics Committee. University of Sheffield Ethics reference number 018989.
Nine clinical supervisors from different medical specialities, with a mix of age, gender and trust location, were recruited for the study. Numbers were chosen based upon experts in IPA methodology, who advocate that sample size is contextual and that a small number of data points is more appropriate with a limited number of key themes being identified and explored (Smith, 2009). Interviews were transcribed verbatim and thematic analysis using NVIVO 12.
The key themes from the analysis, around the tensions between service and educational delivery are the focus of this paper.

Results/Analysis
Supervisors were very aware of the challenge of managing the tensions between service delivery and education but overwhelmingly acknowledged that everyone was doing their best in a high-pressure system. It was clear that it was felt that there was a lack of coordination between the Medical School and the NHS trusts themselves, without any clear solutions being offered that might provide resolution.
"You want to give them a good attachment but at the same time you've got so much work to do" Respiratory Consultant 1. Impact of working patterns Some participants suggested that there is a particular tension around working patterns. The traditional model of consultant led teams is less common, as shift working and split patterns are used to deliver care within the required contractual hours of staff. It was suggested that this might lead to a lack of continuity; especially in terms of the students seeing the supervisor enough times to ensure appropriate sign off on their job assessments. This could also have an impact on the community of practice and the potential opportunity for participatory practice unless somehow these are aligned.
"We have moved away from the concept of a clinical team. When I was a junior doctor you worked on a team where you had one consultant…a registrar, you had 2-3 junior doctors and you all worked together as a team….so you knew everybody well. Now, with the way things have changed that no longer exists" Gastroenterology Consultant These comments from supervisors were set against a background of they themselves feeling that they were missing the contact with students and they felt that this was holding back their ability to deliver the standard of placement that they sought to achieve. It is unrealistic to expect that there can be a reversal of some of these changes in an increasingly high demand system. However it is important for those setting the placement objectives to recognise that whilst the "what" of medical education may not have dramatically changed, the "how" certainly has but not necessarily with the two aligned effectively.

Structural challenges
Staffing and environmental issues were identified by two supervisors. These were both in care of the elderly, in a single trust, where a recent issue had led to them having to move from their usual wards. This had left their patients in various locations around the hospitals, including some at a second site some distance away, on wards not designed for delivering this speciality. Whilst specific to their current circumstances, their comments raise the issue that the environment itself can be a significant barrier where it prevents effective and high quality education. Hospitals are not built to be educational facilities, they are built as healthcare facilities and it is clear that sometimes these restrictions themselves lead to limitations in the quality of teaching that can be delivered.
"That last ward environment we were on was awful and the MDT room was tiny. We were virtually sitting on each other and at that point, unfortunately the people that were getting pushed to the back and pushed out were the students, which is awful" Care of the Elderly Consultant Whilst almost all hospitals have medical education centres these are designed for more specific education activity, such as lectures or seminars, rather than the experiential and supervised participatory practice within the clinical environment that we seek to achieve. If we are developing healthcare facilities for the future it will be important that we consider the wider infrastructure with education in mind, integrating the education and service delivery needs rather than separating them.

Personal impact of tensions
Gray J MedEdPublish https://doi.org/10.15694/mep.2020.000133.1 Page | 4 Supervisors reported a personal impact of the tensions. When asked whether there was pressure from management to reduce education, one supervisor candidly stated that there was not. However, there was an expectation that the work would get done as well. This means that there is a potential effect on supervisors where they themselves are impacted rather than simply the students. This impact is unlikely to be overtly recognised by students yet is clearly of significant importance to the well-being of the education system and the risk of burnout amongst senior clinicians. In this context the ethics of care plays out in the conflict of education and service delivery. Whilst authors have considered this within the healthcare context, considering in particular the challenge of balance of care between patients from any particular healthcare professional (Nortvedt, Hem and Skirbekk, 2011), there is a need to reframe this and consider the way it is interwoven with the educational element. Supervisors clearly understood their responsibilities to the education of students as well as their patients however it raises the question as to whether there is a need to widen this discourse to one which extends this ethical framework to the complex relationship between hospital trusts and medical schools.
"I've probably not managed it well at times. I perhaps spend too much time with the students and then it means I am stuck doing my admin until 7 at night and don't get home for a meal with the family…" Cardiology Consultant Supervisors expressed that this personal pressure was not just about the desire to deliver the teaching but, that whilst doing so, the other work did not just disappear and still needed to be completed despite the requirement to undertake teaching. The feeling was that whilst there was no particular pressure from the hospital management to prioritise service delivery over education, the impact was felt through the demand on the individual supervisor, as there was no removal of work from supervisors or teams to create space for education to occur in.
Supervisors all felt that they had to ensure that they managed the pressure that blending education and service delivery causes by working with the students. The focus of this was ensuring that students had appropriate expectations of placement based education, and recognised the requirements that the supervisor had on their time due to delivering the service requirements of the NHS. It was clear that the supervisors all recognised the need to ensure that students knew that there was a plan for their education and that they were not simply being "brushed off" when service commitment impacted on planned educational activity.
"I think being honest with students is important as well. I actually say, "It's really rubbish at the moment, it's awful this morning" and I have said it and sometimes I've said, "go away for a couple of hours and come back later" and I'd rather have that than loiter in the corner" Care of the Elderly Consultant All of the supervisors felt that managing the tension effectively required students to be realistic regarding their expectations of direct supervisor teaching within the placements, in order to allow supervisors to work with them effectively and ensure they had the best quality experience. The Medical School has stated expectations of the direct teaching to be delivered in a week although it was unclear whether this was well known by the students or supervisors. The findings suggest that if education and service delivery can be more effectively blended then this will benefit both the education the students receive as well as the supervisors own internal tensions to deliver care and teaching.
"I'll say to the students, I'm quite good at teaching, I'm quite good at outpatients, I'm absolutely rubbish at trying to do two at the same time and so forgive me" Care of the Elderly Consultant The supervisors all talked about the need for students to recognise the tension as one of many that they will themselves encounter when working in the NHS.
"They need to understand that we've a job to do and that patient safety comes first. That they need not to mind" Care of the Elderly Consultant Gray J MedEdPublish https://doi.org/10.15694/mep.2020.000133.1 Page | 5 It was clear that supervisors saw this tension as part of the hidden curriculum of placements in hospital trusts and that students equally would learn about how to manage things better, when they themselves were the teachers, through observation of the supervisors coping mechanisms and the way they managed this conflict. Supervisors talked about always giving students a plan to ensure that they remained engaged, recognising that the way they talked and acted when addressing such issues was itself crucial. One supervisor likened it to 'moving pieces on a chess board', with the need to, at any moment, find the "right move" for students to get the most out of the placement. This reflects back to the discussions around ensuring students have a clear timetable and are effectively directed.

The potential for students to help manage the tension
This generated a large amount of discussion. The premise was whether students themselves could help manage the tension between education and service delivery. If it is acknowledged that placement based education is, in many ways, akin to an apprenticeship then it could be argued that there may be some value.
All supervisors felt that if the students had the right understanding of the tensions that existed they would be better able to support the tensions and have a higher quality educational experience as a result. They all talked about how they manage this, and try to aid the students understanding of how teaching could, and would, happen regardless of the pressures existing at any particular time. They also focussed on honesty about current pressures.

"I think when you are busy, there is something about being honest if you are busy and I can't do this now" Care of the Elderly Consultant
It was not clear as to whether the supervisors felt that Sholls "tightrope" was being effectively balanced or not, however what was clear was that they all had a wide variety of teaching methods they employed to work around the existing tensions in an attempt to ensure quality is not diminished in a busy environment (Sholl, 2018). All of the supervisors recognised that teaching was a core part of what they had to deliver regardless of any existing pressures.
"Whilst there is a tension, and it can be frustrating, it's the way it's always been. If we're not going to be teaching them then who is" Acute Medicine Consultant The role of students in managing the demand was a core theme which revolved around the level at which the students were at in their training. All of the supervisors felt that there was certainly enough work to be done and that more hands would be valuable. It was the form that this could take that varied with some seeing more barriers than benefits.
The impact of the level of training students had had with respect to managing demand was discussed by all of the supervisors. They felt that those most likely to be helpful would be those toward the end of their training, particularly in the shadowing phase of the course, as they also had a particular desire to be undertaking all the processes and procedures that they would perform when qualified.
"Shadowing students, they are very useful clinically….because they want to understand how the system is going to work and they can often be left to get something done and come back and give you information that's useful. I think the more junior students who haven't perhaps seen that many patients, when it's really busy in winter that is more difficult" Respiratory Consultant The comments suggest that students whose skills and knowledge are becoming most closely aligned to the community of practice they are soon to join are those perceived as having greatest ability to support the tension. One supervisor commented that the medical ward environment was potentially quite intimidating for students and felt this would be a barrier however an argument could be made that, if they feel part of that ward community, this should not be insurmountable. No comment was made as to whether this was borne of experience from student Gray J MedEdPublish https://doi.org/10.15694/mep.2020.000133.1 Page | 6 feedback or whether this was their personal perception. It is unclear as to whether any real consideration had been given to the more junior students, their skill set and their ability to assist in managing the tension in its widest sense but that is perhaps a piece of work for the future. Whilst supervisors were unclear as to the exact benefits the students may provide in managing service demand they had considered how some activities had the potential to be both supportive to managing service delivery but also useful with respect to education. Examples were students seeing patients in the outpatient clinics and undertaking specific clinical tasks on the wards which some supervisors saw as allowing them to do some bits of their role slightly more quickly.
"Go and start seeing that patient and then tell me……that actually might help me because I've never met this patient before and you are giving me some information" Care of the Elderly Consultant Overall, it was felt that whilst there may be some role for students toward the end of their training, there was limited scope for more direct student support for these tensions between service and education. Notably, the themes, mentioned previously, around helping students gain a better understanding of what education looks like in the ward environment, and recognising teaching that does not fit with their usual perception of didactic learning, came through strongly as this eased the feeling of pressure on supervisors and their teams.

Discussion
This work highlighted the challenges of delivering education within the context of a high demand service yet it could be said that the reduction in time for more didactic bedside teaching has driven the change to a supported practice model of education in line with the current view of best practice. In this situation the proverb "necessity is the mother of invention" clearly stands true. In considering ways to manage the tension between service delivery and education supervisors have sought, and implemented, solutions which fit with the recognised educational direction of travel for students in this clinical environment. In this way the concepts explored in the management literature appear to translate into the clinical environment with the tensions being present but the supervisors recognising these and responding accordingly. In making these statements however, we must recognise that this group of supervisors are potentially above average in motivation therefore we cannot assume that the solutions that they have implemented will be replicated across all supervisors. It is important that we recognise that, along with the solutions raised by the supervisors in this work, there will be others and consideration should be given to a piece of work to gather up the solutions to this pedagogical balancing act which supervisors have found to work well in order to spread out this learning. Given the supervisors comments around the pressure on their time preventing them engaging more fully with the Medical School it is incumbent upon the school to lead such a piece of work for the benefit of its students and supervisors.
Previous work has emphasised the need for a shared mental model between service and education provision for both to successfully co-exist (Turner, Fielder and Ward, 2016). The findings of this study raise questions regarding the current state of this shared mental model and whether, at present, it is being successfully achieved. Clinical care delivery and clinical education cannot exist in isolation of one another. It could be suggested that hospital trusts and Medical Schools have a symbiotic relationship, with clinical education unable to exist without care to provide but care unable to take place without a ready supply of trained clinicians. Whilst funding follows the student into hospital trusts it is unclear as to how this then is utilised in order to create a balanced coexistence of education and service delivery.

Conclusion
If we are to address the issues raised here it is vital that Medical Schools and trusts work together to recognise the Gray J MedEdPublish https://doi.org/10.15694/mep.2020.000133.1 Page | 7 symbiosis that exists and decide how they can best build upon it in order to improve the placement experience. Crucially this dialogue needs to be at a senior level within the trusts. The risk of education being pushed aside, as trusts tackle the significant challenges they have meeting the demand for patient care, is high and without senior level leadership is likely to lead to the status quo being maintained.
It would be easy to see this as predominantly an education issue however, with the known shortages of junior doctors nationally, it is in the interest of hospital trusts to provide a high quality educational experience thinking toward future workforce recruitment. The evidence clearly shows that high quality educational experiences are more likely to lead to positive changes in students professional intentions with respect to potentially working in any particular location (Johnson et al., 2018). Once again this is a joint challenge and cooperation will be crucial for all parties to get a solution that can be stronger than the sum of its parts.

Take Home Messages
There is perceived to be a lack of coordination between medical schools and hospital trusts. Closing this gap 1.
is crucial to improve placement quality. The traditional team structure has changed, however medical education has not yet adapted to it. 2.
The physical environment of a hospital can be a barrier to effective education and needs to be considered by 3.
hospital trusts when developing their premises.
There is a personal impact on clinical supervisors due to these tensions. Medical schools and hospital trusts 4.
need to better understand this and support them. There may be a role for students to help manage these tensions but it needs leadership from educators as to 5.
how the pedagogical aims can be met through aspects of service.

Notes On Contributors
Dr James Gray is Senior University Teacher at the University of Sheffield and Course Director of the MMedSci in Physician Associate studies. He is a General Practitioner at Meadowgreen Health Centre in Sheffield.