Explanation of Medicine Clinical Faculty’s Experiences of Clinical Supervision: A Qualitative Study

Background: Educational clinical supervision is the direct or indirect supervision by the clinical supervisor of the processes performed by the student in clinical environments for providing guidance and feedback with the point of executing better and higher quality attendance to patients. Given that this supervision is one of the main activities in the teaching of the medical Career, The aim of this study was to explain the experiences of clinical faculty regarding educational clinical supervision. Method: This study is a Qualitative study and it was performed with the participation of 13 faculty members of the internal medicine and surgery departments of the medical school of the Islamic Azad University, Najafabad unit. The sampling method was purposeful and the data was been collected via semi-structured computing. Data analysis was been done by using analyzing qualitative content method with the Deductive approach. Results: They were placed in 3 main classes and 12 sub-classes. The main categories include fundamental roles, relaxed alertness, and Counterproductive behavior. Conclusion: Not attending to the challenges of didactic clinical supervision and the lack of a suitable supervisory structure will cause the reduction of the motivation of faculty (board) members and an increase of their confusion, as well as the formation of anti-production behaviors and reduction of the quality of clinical education.


Background
Universities of medical sciences are responsible for educating physicians who, after graduation, could endeavor to promote community health by performing their professional duties and adhering to the speci c principles required by this career. In the educating of medical staff, in addition to the knowledge and skills that are necessary to engage in this career, attention should be paid to the development and ampli cation of values, theories, moral norms, social skills, and other characteristics that shape the human behavior of a physician or professional skills (1). Clinical education is one of the situations that provide an opportunity for the student to learn his theoretical knowledge of the various mental, psychological, and dynamic skills that are necessary for patient care (2).
It is obvious that in this area weak planning causes problems that nally will lead to poor professional skill and decrease graduates performance (3). It should be noted that the learning of medical students in the clinical environment is greatly affected by the effectiveness rate of this educational environment (4).
Among the common problems in medical education that have received less attention are the stressors of student's clinical environment that can affect clinical education (5). Students, as recipients of educational services, are the best source for identifying educational problems, because they have a presence and direct interaction with this process. Identifying the status of clinical education helps to eliminate or correct weaknesses and can improve the achievement of educational goals, train skilled people and provide quality care services (3). Among the main activities in care jobs is supervision in clinical education(6). Clinical supervision, direct or indirect supervision by a clinical supervisor of professional projects or processes, performed by a student or group of students in a clinical place, for guidance, feedback, personal, professional, and educational evaluation in order to provide better care and better quality, safe and suitable for patients (7). The educational role of clinical supervision is so prominent that the UK department of health has recommended familiarity with the clinical supervision process in the vocational training course(8). Also, in the United Kingdom, clinical supervision is a tool for professional training and improvement (for example, the acquisition of medical skills) and supervisory performance with Mentorship and Preceptorship (9). However, reviewing the evidence shows an increase in mortality in the surgical, anesthesia, trauma, emergency, and obstetrics, and gynecology departments due to insu cient oversight of student's activities (10).
Also, another study showed that in one of the hospitals, the cause of frequent deaths in effect mild appendicitis was due to the inability of medical interns to examine the radiography. The authors stated that insu cient oversight of student's activities endangered patient safety. (11). Also, in Iran, Razmjoo et al., in a study comparing the attitudes of faculty members and medical assistants about the clinical supervision of residents in Tehran educational hospitals, concluded that there is no effective clinical supervision of the training of residents in the hospitals under study (12).
According to this issue that, general medicine plays a fundamental role and position in the system of providing services and promoting public health (13). Consequently, clinical supervision in clinical education environments is one of the methods to enhance the quality of clinical education. It is extremely signi cant to identify the clinical professors' understanding and experiences as providers of clinical education and supervision. Accordingly, this study was conducted in order to explain the clinical faculty members' experiences towards the clinical supervision training strategy.

Method
This study is a part of the master's thesis in the eld of medical education approved by the ethics This research is qualitative research that was conducted using the thematic content analysis method.
Participants in this research were clinical faculty members of the Internal Medicine and Surgery Departments, Faculty of Medicine, Islamic Azad University, Najafabad Branch who had the inclusion criteria (having at least 4 years of faculty membership in the Islamic Azad University, Najafabad Branch, experience in educational activities in medical sciences for at least 4 years).
Participants in the study were recognized employing purposeful sampling. In the next step, they were invited to participate in the research by telephone. The researcher explained the objectives of the research to the participants before each interview and the time and place of the interview session were arranged after obtaining their agreement and consent. Sampling was continued until data saturation. All interviews were conducted from May to October 2019.
Data was collected through semi-structured face-to-face interviews. The mean time for each interview was 50 minutes. The required explanations were presented about the right to leave the study at any time they wanted and the con dentiality of the text and audio of the interviews in each interview, after getting consent to record the interviews from the participants.
The interview started with the phrase "Please explain what you do during your internship day" and then continued to more detailed questions based on the participants' responses. All questions were asked about the supervision of clinical medical education.

Results
In this qualitative research, the experiences of 13 clinical assistant professors of surgical and internal medicine departments of the contracted hospital of Islamic Azad University, Najafabad Branch, were analyzed employing inductive qualitative content analysis with the Krippendorff approach, which knows the content analysis process as collecting data, unitization, sampling, report, data reduction, inference, and analysis (14). The beginning of the analysis operation started after the rst interview and the coding and classi cation after the second interview. This helped the researcher design the other required questions and better conduct the study path. Consequently, the following steps were thoughtfully followed in data analysis: All interviews were implemented word-for-word, texts were examined line-by-line. Meaningful sentences related to the main topic of the research were then marked. The main concept of meaningful sentences was extracted in the form of code and the classi cation of codes started. In this way, codes with common sense were arranged in a category and named. The earlier categories were reviewed and merged, or a new category was formed with each new interview. The classi cation and naming performance of the classes were then reviewed under the supervision of an observer with experience in qualitative data analysis. Consequently, the principal themes of the study were extracted and the relationship between classes was recognized by forming a classi cation.
At the time of data analysis, it was tried to avoid any assumptions (15). The interview texts and codes extracted by both authors were examined to assure the accuracy of the codes, naming of categories, similarities, and differences to increase the validity and reliability of the research (16). During the data analysis, the researchers interacted with the participants and were given a summary of the researchers' interpretation of the ndings to verify or correct the results.
Participants were selected with the highest diversity and the data collection process was continued to saturation level in order to increase the validity of the research. The achieved codes, subclasses, and categories were veri ed by an expert in qualitative research who did not participate in the extraction of the results to increase the reliability of the research.
Participants in this study were 13 faculty members with a mean work experience of 11.3 years, 3 women and 10 men, 6 surgeons, and seven internal medicine specialists. The results were achieved by analyzing 13 interviews directed to the creation of 229 initial codes, in which the number of codes was reduced to 63 codes after eliminating duplicate codes and merging similar codes.
The codes obtained from the perceptions and experiences of faculty members were nally set in 12 subcategories and 3 main categories, including fundamental roles, conscious ataraxy, and Counterproductive behavior. These categories include subcategories that examine different aspects of educational clinical supervision strategy ( Table 1). The ndings of the research are presented along with a selection of texts from the conducted interviews. Educational abilities are one of the principal skills of an educational supervisor. In this study, faculty members believed that the clinical supervisor has fundamental roles that play a signi cant role in accomplishing educational objectives. Participants in this category introduced concepts such as diversity in education methods, a re-examination of speci c patients, assistance in increasing competence, Socratic questions and answers, and support.
A faculty member states in this regard: "We had around every day. We did both stager and intern rounds. In detail, I usually operated in the part where we were talking about the patient and the patient's problems. From pathophysiology, diagnosis, treatment, etc., in the classroom, "We were operating to perform the tasks of the department that was a topic that we had presented them, consequently, we could theoretically explain to them, for example, an electrolyte disturbance." Interviewee 13 Another faculty member stated the following statements: "We monitor what they do and what we check their daily note works if they have a problem or the history they write if they have a problem. We explain to them not to write like that for the next time or to correct their diagnosis next time." Interviewee 12

Relaxed alertness
Relaxed alertness means dismissing the learner's fear and inspiring him/her to internalize the achieved information. Participants in this category explained concepts such as teaching professional behavior, providing a friendly atmosphere, respecting patient rights, utilizing other medical professions in student education, and assessing student progress.
A faculty member stated in explaining his experience: "Interns should wash their hands in the operating room, and I teach them how to put chest tubes. I allow them all to do sutures. "If they are very interested, I will allow them to excision... I even had an intern who even performed laparoscopy for a broken hand, which was exceptional ... "Interns, I do pleural uid or suture in the ward. Let the interns see what I do." Interviewee 5 A faculty member says about teaching ethical tips: "... I try to tell them something about our medical ethics. For example, things like the patient's name are said a lot or which hospital it is in determining the history, and they say things that it is not necessary to say. The history and examination should be more scienti c. They should not state the patient's private issues Interviewee 9

Counterproductive Behaviors
Counterproductive behaviors are behaviors in which a person cries and violates customs, policies, rules, and regulations and has a damaging effect on education and students, including inhibition of achieving the objectives, underemployment, waste of time, aggressive and violent behaviors such as threatening, severe verbal warnings, verbal violence in the form of cursing and insults, abuses, ridicule and discrimination (17). Participants in this category referred to concepts such as not allocating enough time to education, inadequate clinical education, prioritizing treatment, and visiting patients in other hospitals to educate, bored state, and unmotivated manner related to the professors.
Faculty member number 1 says: "... In the second and third sessions, according to their interests, some of them do not show much interest until the end, and we have nothing to do with them so that if they are not interested, they will not even their hands and just watch. Interviewee1 Faculty member No. 8 says about dedicating little time to education: "We have to pay attention to two issues. Well!? One case refers to the internship training issues and the other has to pay attention to my medical tasks. For example, now that I am going to the clinic, well, I must be aware that I have to go to visit these forty patients so that my organization and my patients do not complain. " Interviewee 8 The concept of educational clinical supervision strategy Nevertheless, most participants declared that they were unfamiliar with the term educational clinical supervision. They explained the concepts such as educational supervision of student actions, the presence of the professor during clinical procedures, reviewing the quality of student actions, evaluation of teaching methods, information transfer, student evaluation, educator evaluation, providing feedback and direction.
One of the faculty members stated: "We monitor how the students are educated as well as the practical tasks they perform. The tasks that are already being educated and they have to do them right. now" Interviewee 3 Another professor states: "Monitoring, which I think occurs every day, now we do not know its name, but it occurs every day. Because it is an order and they have to write, interns write the orders before we come. That is, we should pay attention to this record that they make because they write the situations of the patients also in the le. It is possible to us how he/she examines, how he/she treats the patient in each encounter. How does he/she behave in his/her clinic and how does he/she read the things that we now add to the case? Does he/she really go and read from the text or not, he/she tells something of himself /herself. In short, this is how one professor monitors the students. Interviewee 2

Clinical supervision structure
The statements of all study participants showed that, although other medical personnel is sometimes employed to monitor students' clinical actions. Notwithstanding, most supervisions are provided in groups and by an observer, is usually the relevant professor; and in general, the supervisions performed do not have a formal structure and no speci c model is employed to perform the supervisions.
A faculty member stated: "... I ask others to check their histories and examinations. What is wrong with them? I try to tell them rst what should they have asked or added. If they do not say it, I will say that it is wrong ...". Interviewee 5

Discussion
This study was conducted based on the experience of researchers with medical students in clinical education and the O ce of Medical Education Development and generally to explain the experiences of clinical faculty members in general medicine concerning clinical supervision training strategy.
The following part shows the descriptions of the categories obtained from the participants' experiences of the current state of clinical supervision, including fundamental roles, relaxed alertness, and Counterproductive behavior, which expresses the different, unique, and multidimensional tasks and capabilities related to the clinical supervisor.

Fundamental roles:
The clinical supervisor is responsible for supervising the trainees' clinical practice during the internship and providing appropriate feedback to the trainees, and also verifying the trainee's entry into the next stage of training(18).
The results achieved by the study conducted by Kilminster &Jolly also showed that one of the most fundamental criteria for clinical supervision is to provide clear feedback (19). In this study, the participants additionally included different skills and competencies that are compatible with many studies.

Relaxed alertness
The atmosphere of the educational environment, facilities, and equipment, personnel, patients, and educators are among the factors in uencing the clinical environment. Each of these factors will play a fundamental role in the rate of educational e ciency and patient care offering(3). Pazokian & Rassouli suggested in their study that one of the strategies to achieve effective education is systematic evaluation and provide feedback to all educational stakeholders, from students to administrators and planners (20). Participants in other studies also admitted that paying attention to students' points of view and thoughts can be useful in forming their relationship with professors and lead to a direct effect on the process of teaching and learning (21). Participants mentioned similar concepts consistent with these studies in this study.

Counterproductive behavior
The role of clinical supervision of faculty members, voluntarily or involuntarily, is affected by multiple educational, supportive, consultant, therapeutic, and sometimes executive responsibilities. Accordingly, the clinical supervisor suffers from a kind of disagreement in behavior to perform all these roles and due to facing the double pressure caused by multiple tasks and trying to adapt the roles of each task and con icts resulting from the con ict of interests of these roles that result in expressing challenging behaviors such as disrespectful behavior of the professors towards the students, humiliation of students with offensive words, frightening or insulting them, indifferent treatment with the student or distancing oneself from the student, in exibility (22). Findings from Donough et al.'s study also revealed positive and negative experiences with clinical supervision, so that students described the support they received from supervisors as positive experiences and the abuse they received as negative experiences (23).
In this study, types of verbal and physical violence, disobedience, anti-social behaviors, harm to the interests of the organization, and inhibit accomplishing objectives have been classi ed as Counterproductive behavior. Counterproductive behavior with individual's behaviors and violating the rules and regulations of the organization harm the organization and its employees. It is not possible to achieve a comprehensive and complete de nition that separates Counterproductive behaviors from other studied behaviors by examining the theoretical foundations and de nitions provided by organizational behavior researchers about the employee's negative behaviors in the workplace. Bennett and Robinson (2003) and Marcus and Schuler (2004) have focused on understanding Counterproductive behaviors in their research because they believe that this approach enables researchers to additionally theorize about the in uence of common factors on behaviors contrary to organizational expectations (24).

The concept of clinical supervision
Clinical supervision is de ned as direct or indirect supervision by the clinical supervisor of professional projects or processes performed by a student or group of students in a clinical environment and providing guidance and feedback; and personal, professional, and educational evaluations to provide better, more quality, safe and appropriate care to patients (7). Evidence implies that there are different de nitions of clinical supervision and that there is still uncertainty about the true meaning of the word(18, 19). Participants offered different concepts and various perceptions of educational clinical supervision consistent with other studies in this study, although most participants stated that they had never heard of the term educational clinical supervision, according to the meaning of the word and the experience of educational work.

Clinical supervision structure
In this study, monitoring is performed in groups and sometimes by other medical personnel. This study is similar to the group clinical supervision structure in terms of grouping, which is the most prevalent structure employed in clinical supervision, in which a supervisor controls a group of students. But each student is given time to present a case in this structure, and most of the interactions have occurred between the supervisor and the presenting student (25), which is not consistent with this study in this respect.
Also, the non-model model is used to provide clinical supervision in this study. In this monitoring model, clinical supervisors are selected because they are good therapists, physicians, and counselors, not because they have been trained to be supervisors (65)24.

Restrictions:
One of our restrictions in this study is the lack of generalization of results to other universities. It is recommended that the generalizability of the research results be increased by conducting widespread studies in this eld and selecting participants from different educational groups and diverse universities.

Conclusions
One of the practical and effective educational approaches to obtain the necessary clinical competencies in medical students is the educational strategy of clinical supervision. On the other hand, regardless of where do clinical faculty members live in the world, they face common concerns when playing multiple roles, and their greatest challenge is role therapy. But as the research ndings displayed, what is obtained from the combination of therapeutic, executive, educational, and supervisory roles of faculty members is the disagreement of roles due to the simultaneity of their various roles, which will dominate their supervisory role. Consequently, not paying attention to the challenges of educational clinical supervision strategy and lack of proper supervisory structure by reducing the motivation of faculty members and expanding their confusion causes them to form Counterproductive behaviors and results in reducing the quality of clinical education.

Abbreviations
Not applicable Declarations Ethics approval and consent to participate: This study is a part of the master's thesis in the eld of medical education approved by the ethics committee of the medical education faculty of Shahid Beheshti University of Medical Sciences with the ethics code IR.SBMU.SME.REC.2019,007.

Consent for publication:
Not applicable Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Funding:
No funding institution in the design, collection, analysis, and writing of manuscripts.