Pedagogic strategies of supervisors in healthcare placements

Abstract

Purpose

Supervisors are responsible to train students in healthcare placements. Although there is knowledge about workplace learning and supervision in general, little is known about supervisors’ pedagogic strategies in specific healthcare placements. In this study, we identify how supervisors’ reasoning and interrelated actions manifest in physiotherapy and nursing work settings.

Methods

Following the stimulating recall approach, we conducted 16 interviews with supervisors at seven work settings. Using a theoretical framework of workplace supervision, we performed a deductive template analysis.

Results

Four configurations of pedagogic strategies reveal how supervision manifests in healthcare placements. The results provide unique insights into specific supervision moments, and elucidate the situatedness of the supervisors’ strategies.

Conclusions

The present study illustrates the variation in aims and focus of supervisors in placements. Supervisors’ pedagogic strategies were found to be mainly based on (A) role modelling, (B) overall support, (C) trust, and (D) letting go. Further research is needed to investigate the interplay between supervisors and students in learning situations within work settings.

Keywords:

• Placements
• supervision
• pedagogic strategies
• workplace learning

Introduction

In healthcare placements, supervisors are challenged to train students in becoming entry-level professionals. These supervisors have, alongside everyday work, an important pedagogic role (Billett et al. 2018). They are expected to have expertise in their own professional domain and expertise in supervising students’ learning in placements. Supervisors are engaged in students’ learning process when they work together and undertake interventions, such as giving explanations, providing feedback, or discussing a patient case (Mikkonen et al. 2017; Ceelen et al. 2023). Moreover, students’ participation in daily work activities in interaction with their supervisors and other co-workers is central to preparing them for their future roles as practitioners at the workplace (Vygotsky 1986; Lave and Wenger 1991; Billett 2016). Although there is a reasonable body of knowledge about workplace learning and supervision in general, little is known about how supervisors’ pedagogic strategies manifest in specific healthcare placements.

Practice points

• Supervisors have an important responsibility to train students in healthcare placements.

• Understanding supervisors’ pedagogic practices includes not only the actions that supervisors undertake but also the reasons underlying these actions.

• The focus on demonstration, stimulated participation and entrustment provides a template for framing pedagogic strategies of supervisors.

• Four configurations of pedagogic strategies show how student-physiotherapists and -nurses are supported to learn at the workplace differently, either based on (A) role modelling, (B) overall support, (C) trust, or (D) letting go.

• Workplace supervision is always embedded in specific work contexts, and is shaped by unique interactions between supervisors and students.

Pedagogic strategies are a result of supervisors’ deliberation of how to most successfully supervise students. These strategies are based on supervisors’ reasoning and interrelated actions (Khaled et al. 2021). Therefore, to understand the pedagogic strategies of supervisors, we need to investigate not only the interventions that supervisors undertake, but also the rationales underlying the supervisor-actions (De Bruijn 2012). Furthermore, pedagogic strategies of supervisors should not be separated from the context in which they occur because workplace supervision is embedded in specific work settings, also referred to as communities of practice (Lave and Wenger 1991). Through supervisors’ engagement in social participatory processes with students in local communities of practice, supervisors gradually develop comprehensive pedagogic strategies, explaining how and why they contribute to students’ workplace learning (Hauer et al. 2014; De Vos et al. 2022).

To grasp pedagogic strategies of supervisors in healthcare placements, a three-way focus on workplace supervision provides a theoretical framework (Ceelen et al. 2023).

1. Demonstration: fostering students to learn through observations and imitations, and affording the students to learn through supported participation, for example by providing them with opportunities to receive direct feedback (Billett et al. 2014).

2. Stimulated participation: preparing students to contribute as (full) team members and stimulating them to develop a professional identity (Goller et al. 2019).

3. Entrustment: promoting students’ independent practice, including the constant judgment processes of supervisors when reasoning about ways to foster students’ autonomy in work activities (Ten Cate et al. 2021; De Vos et al. 2022).

To improve the understanding of how supervisors’ pedagogic strategies evolve from demonstration, stimulated participation, and entrustment in particular work settings, an empirical investigation of workplace supervision is required. Through interviewing supervisors, we will be able to learn about contextualised manifestations of workplace supervision in real-life work settings. The research question of this study is: Which pedagogic strategies of supervisors can be identified in student-physiotherapists’ and student-nurses’ work settings?

Methods

Context

In the Netherlands, Health Profession Education (HPE) for physiotherapists and nurses comprises a 4-year bachelor’s course for full-time students, accredited as level 6 of the International Standard Classification of Education and European Qualification Framework. In their final year, students participate in a placement for 3 or 4 days a week during approximately half a year. During the final placements, the focus of supporting the students’ learning is predominantly on developing professional competence towards an entry-level practitioner.

In this empirical study, we focused on work settings that provided a 20-week placement in the final year of student-physiotherapists and student-nurses in HPE. In these work settings, students were paired with one or two supervisor(s). Those supervisors worked as experienced physiotherapists and nurses, and were assigned a role to supervise students. In certain work settings, supervisors guide multiple students. However, in each work setting, we studied the supervisor’s pedagogic strategies in relation to an individual student.

Participants

Ten supervisors in seven work settings were selected to participate in the present study, using a convenience sampling method (Table 1). Teachers from the physiotherapy and nursing education programs at three Universities of Applied Sciences in the Netherlands were asked to contact workplace supervisors that they considered to facilitate representative placement experiences to students (Miles et al. 2014). Prior to data sampling, supervisors and students were informed about the research design and given information letters. After a period of consideration, they agreed to participate in the study and informed consents were signed. Management staff gave written permission to conduct the study within the organisation.

Table 1. Context of data collection.

Work setting	Description
Rehabilitation centre	Military rehabilitation centre where patients often stay in-house and participate in longitudinal interprofessional treatment processes. A fixed agenda determines the daily patient planning of the physiotherapists.
Hospital	Physiotherapy placement including two hospital departments: neurology and gastroenterology. A daily updated overview of patients indicates caregiving activities.
Private practice	Physiotherapy practice located in a community health centre. A fixed agenda determines the daily patient planning.
Hospital	Nursing placement located in the hospital department of gynaecology and urology. Work activities are partly scheduled, and partly dependent on ad hoc patient needs.
Nursing home (elderly care)	Nursing home which accommodates for elderly people who can no longer live independently and require nursing care, including patients with dementia, Parkinson’s disease, physical disorders, and rehabilitation. Treatment schedule is drawn up together on a daily basis with the team of nurses and student-nurses.
Psychiatric care institution	Department of a psychiatric institution for people with chronic depression. Residents stay in-house and participate in longitudinal treatment processes. Daily work processes of the nurses are partly determined in a fixed agenda, and partly dependent on unpredictable patient care.
Home-based care	Patient-care activities takes place at people’s own homes and are pre-assigned among the team of nurses. A fixed amount of time is available per patient.

Data collection

A research design based on the stimulated recall method was chosen to enable researchers to access pedagogic strategies of supervisors in student-physiotherapists’ and nurses’ placements (Lyle 2003; Khaled et al. 2021). Between February 2019 and January 2020 interview data was collected (Table 2). Interview triggers, in the form of photos representing specific supervision moments, were collected in the seven work settings during observation of daily activities and interactions between supervisors and students. The interviews with supervisors usually took place on the same day and otherwise within a week after observation. In the interviews, supervisors were prompted to articulate their pedagogic actions and reasons related to these photos of real-life moments. The 16 interviews were audio recorded, transcribed verbatim, and pseudonymised prior to analysis.

Table 2. Collected data.

Occupation	Supervisors	Work setting	Data collection in 20-week placement	Interview triggers (N photos)	Interview duration (minutes)
Physiotherapy	Jennifer Matthew	Rehabilitation Centre	1: week 7	4	39 52
			2: week 14	6	40 38
	Wendy	Hospital	1: week 7	4	44
	Sara		2: week 15	5	42
	Laura	Private Practice	1: week 6	6	45
	Jessica		2: week 13	4	49
Nursing	Amber	Hospital	1: week 5	4	43
			2: week 18	2	32
	Emily	Nursing home, elderly care	1: week 5	1	34
			2: week 15	1	29
	Amy	Psychiatric care institution	1: week 9	5	55
			2: week 18	2	42
	Britt	Home-based care	1: week 9	3	23
			2: week 19	1	31

Data analysis

A five-step analysis was performed based on a qualitative data analysis approach, and the main steps involved in undertaking template analysis (Brooks and King 2014; Miles et al. 2014) (Figure 1). To explore the data, the first and second author read through multiple interview transcripts. Relevant fragments were coded by the first author (Table 3) using a theoretical framework of workplace supervision for deductive data analysis (Ceelen et al. 2023). Data fragments of the physiotherapists in the private practice were coded independently by the first and second author for reliability reasons. The interpretation and coding of questionable data fragments were discussed in consensus meetings with all authors.

Figure 1. Analysis process.

Table 3. Example of coded data fragment.

Code: Demonstration	Photo	Amber (nurse in hospital) and the student are in conversation in the nurses’ staffroom.
	Actions	Amber reflects how she facilitated the preliminary discussion with the student about the patients through asking her questions: ‘Which patients do you want to take care of today, what is their history (operation e.g.), what is your focus of today’s work activities, what do you specifically want to learn?.’
	Reasons	Amber wishes to stimulate the student to prepare the upcoming work activities. It is important for her that the student understands the patient’s history. She wants to explain to her what to be attentive to in specific patients’ cases, for example, by recognising the possible complications of surgery. Amber reasons that this patients’ discussion beforehand is important for the student, to develop a clinical overview when providing patient care.
	Illustrative interview quote	I think the clinical reasoning beforehand is important, so she knows what to be careful of, and also to be able to understand the whole clinical picture of this patient, including the surgery they have had, in order to estimate how the patient is doing

In the identification phase, the data of four supervisors were further discussed with three authors (LC, AK, and LN) who collaboratively interpreted the data. To find patterns and combinations, the focus of supervisors’ pedagogic strategies was visualised as figures with spheres of different sizes, derived from the number of coded fragments to demonstration, stimulated participation and entrustment. Since interview fragments were regularly double-coded, figures with overlapping spheres were chosen to visualise the interdependence of the three focuses on workplace supervision. Also, the first author completed an analysis summary format for each work setting and each supervisor. To obtain a better understanding of the meaning of these visualisations, all authors discussed them in relation to the supervisors’ analysis summaries, which led to the presentation of four configurations of supervisors’ pedagogic strategies (Results; Figure 2).

Figure 2. Results summarised.

Results

The subsequent paragraphs illustrate four configurations of pedagogic strategies for supervising student-physiotherapists and student-nurses in seven work settings. The configurations represent how supervisors’ pedagogic strategies evolved from a diverse focus on demonstration, stimulated participation, and entrustment (Figure 2). The results are presented with descriptions of specific supervision moments and interview quotes to elucidate the embeddedness of the supervisors’ strategies.

Configuration (A)

In the private practice, Laura’s and Jessica’s pedagogic strategies were mainly focused on demonstrating to the student the needed knowledge, skills, and attitude to become a physiotherapist (Figure 2(A)). In the daily course of their work activities, these supervisors contributed to the student’s competence development by supporting the student directly, using observation and imitation, feedback, questions, and explanations. Through providing direct support to the student, Laura and Jessica aimed to optimise and structure the student’s learning activities. However, with regard to the patient treatments, they wished to be in charge. They did not feel comfortable letting the student do ‘their’ work, as they considered the patient’s interest as highly important.

Laura checked up on the student when she performed a physiotherapy treatment on the patient. She asked the student: ‘do you know what muscle this is?’ Laura explained that she often gives the answer herself to retain the patient’s confidence. ‘Because, at this moment, she [the student] did not answer me (.,), so I told her. I want to protect the student a little bit, and I don’t want the patient to get the feeling of ‘uh-oh, she does not know what she is doing’.’

According to Laura and Jessica, it was important to enable a careful and gradual entrustment of the student’s independency in caregiving activities. Subsequently, the supervisors indicated that they were continuously in the presence of the student, to provide support and take over the student’s work activities when needed. The first consideration related to the entrustment of work activities to the student appeared to be based on the best approach for the patient. The second reason, which makes the presence of the supervisor during patient treatments important, concerned the assessment of the sufficiency of the student’s knowledge base.

The student took a patient history. Jessica complemented the student with additional questions for the patient. Jessica reflected: ‘I have noticed that the student lags behind in taking the anamnesis and doing the patient’s examination. So we have been slightly delayed. (.) That is why I still have to intervene.’

In sum, the pedagogic strategies of Laura and Jessica seemed primarily aimed at training the student’s knowledge and skills. They remained in close proximity to the student to provide direct support, thereby valuing the patients’ interest and being able to intervene in the student’s actions when necessary.

Configuration (B)

Sara (hospital), Jennifer, and Matthew (rehabilitation centre) supported the student from an approximately equal focus on demonstration, stimulated participation, and entrustment (Figure 2(B)). Although they stated that they were often near the student, their actions included alternations of providing direct support and monitoring the student from some distance. They indicated the significance of having interactions with students to manage their expectations, agree on the upcoming work activities and prepare patients’ treatments in advance. Therefore, Sara, Jennifer, and Matthew aimed to promote the student’s overall learning by means of a clear role and task distribution of the supervisor’s and student’s work activities.

During a supervisor-student interaction, Jennifer demonstrated the spinal vertebrae to the student with a jig. She said about this preparative conversation: ‘We discuss things in advance: what is your plan, and what can you do [in the context of this patient]? (.) This preliminary discussion provides the student with the confidence to treat a patient.’

According to Jennifer, Matthew and Sara it was important to be there for the student by taking the time to discuss the students’ learning process and professional development. The supervisors described how they highly valued the students’ participation and were explicitly committed to the wellbeing of the student. Jennifer, Matthew, and Sara wished to ensure the student felt at ease to undertake daily work activities. Although the supervisors entrusted the students to be in charge and partly improvise in patient treatments, they could not fully allow students to work independently.

Matthew listened in when the student interacted with a patient. He reflected: ‘I deliberately sit on the bench somewhere in the back corner, because I wish to interfere as little as possible. And I tend to interrupt quite quickly. So, sometimes, I really have to take a step back very consciously to try not to get on top of things too quickly.’

In brief, the pedagogic strategies of Jennifer, Matthew, and Sara were based at supporting the students’ overall learning process. The supervisors endeavoured to prepare and structure the students’ work activities, as well as address their job satisfaction and professional identity, and provide them with the confidence to perform daily work activities.

Configuration (C)

The pedagogic strategies of Wendy (hospital), Amber (hospital), and Amy (psychiatric care institution) were mainly based on entrustment (Figure 2(C)). An important reason to entrust the students to work independently was based on the confidence that the student would inform them, or others, when they needed help. Furthermore, most patient cases were discussed with the supervisors before and/or after patient visits.

When Wendy was unexpectedly scheduled in the morning for other activities, she was not able to do a joint start-up with the student. She made sure she carried a phone and could be reached: ‘If anything happens, the student can always call me. That’s the idea, that I’m always accessible.’

According to the supervisors, the students’ participation in their work settings could be characterised as collective in nature. Although the supervisors were not always physically present with the student, they felt that the students enjoyed an approach based on equality. An important consideration that benefited the supervisors’ entrustment of student participation related to the nature of the work structure in which students always worked in close proximity to other colleagues and peers.

Amy considered the student’s reflections as in-depth and she appreciated how the student had initiated feedback-discussions with multiple colleagues. She described how supervising is a collective practice in the psychiatric care institution: ‘Indeed, the student receives a lot of feedback from different co-workers. (.) And therefore, I am inclined to ask my colleagues every now and then: ‘do you have any further details about this student, or something that we need to pay some attention to, (.) and do you agree with me that things are going well?’.’

The pedagogic strategies of Wendy, Amber, and Amy seemed primarily based on trust. They acknowledged the importance of approaching the student as an equal partner. Through the collective character of working together as a team, the supervisors described how they were able to monitor and entrust students to operate independently in work activities.

Configuration (D)

Emily (nursing home) and Britt (home-based care) in particular used pedagogic strategies that were focused on stimulating participation and entrustment (Figure 2(D)). For Emily and Britt, the students participated as full team members. According to the supervisors, the students’ full participation was a self-evident fact in their work settings. Emily and Britt did not actively participate in the daily patient care activities as the student does. As a result, they were not present when the student participated in caregiving activities and there was no, or very limited, direct interaction between the supervisor and the students throughout the placement days. Emily and Britt indicated how they indirectly supported the students’ learning, for example, by enabling them to have access to a phone and patient files, and stimulating them to use learning objective forms. In regular feedback conversations, the supervisors stated that the students themselves indicated what kind of support they needed from their supervisors.

Emily described how she suggested that the student, as part of a school task, could be assigned to take the lead in the morning discussions when the nursing team allocates the patients among the colleagues. Emily explained: ‘The student learned a lot from this (.). The team collaboratively supported her to take this role, but I think that she has really grown by just doing it in practice, going for it.’

Emily and Britt rationalised entrustment as a matter of logic. Because the students were approaching graduation, it felt appropriate for them to provide the students with an individual workload, in accordance with full participation. Another reason to fully entrust student participation related to the supervisors’ comments that the patient care activities in their work settings were usually not very complex in nature.

In home-based care, the student visited all of her patients individually. Britt reasoned: ‘Our patient care is not of such complexity that someone has to accompany her patient’s visit in order to teach her, or supervise her, or whatever. She is able to visit patients independently because soon, she will have to work alone too. I certainly have in my mind, when the student is in her fourth year, that in six months’ time she could have also been my colleague. (.) And I think, that this is in line with the ultimate student’s goal: to be able to go out alone and to experience that she can do it [individually]. If she would be always together with another colleague, she would not know if she could really work on her own. I think it is nice for her to discover ‘o well, I did all those patients’ visits individually today, it went really well, I got nice patients’ comments, and if something happened, I just solved it myself.’

The pedagogic strategies of Emily and Britt were based on a natural letting go of the students. The supervisors’ support included occasional feedback meetings with students and, mostly indirectly, the facilitation of students’ independency as (nearly) professionals and team members.

Conclusion and discussion

The present research studied how workplace supervision is perceived and conducted by supervisors in practice. Since we aimed to investigate supervisors’ pedagogic strategies in real-life work settings, the stimulated recall method helped to ascertain supervisors’ actions and reasoning regarding students’ workplace learning in physiotherapy and nursing placements. An important finding is that the three-way focus of supervision at the workplace (Ceelen et al. 2023) does indeed provide a hold for understanding the pedagogic strategies of supervisors in placements. Although supervisors’ actions and reasoning are shaped by unique learning situations in the daily working life of the seven different work settings, we were able to identify configurations of pedagogic strategies for supervising students. These configurations might serve as a frame of reference for other supervisors and work settings to define supervision in placements.

Despite all students being in their final HPE-year, significant variations were noticeable in the focus of supervisors’ pedagogic strategies. Variety is reflected in the four configurations, which reveals not only different proportions, but also different interpretations of demonstration, stimulated participation and entrustment (Figure 3).

Figure 3. Main interpretations of the four configurations of pedagogic strategies.

Our results illustrate how supervision is shaped differently in various work settings. Although most work settings facilitate similar opportunities to work in close proximity to the student, workplace supervision is manifested differently in practice. Moreover, traditions of local communities of practice might explain why supervision of the students in this study is manifested in different ways in their placements. This is in line with literature describing that the nature of work activities influences pedagogic strategies of supervisors in practice (Benner 2015). Differences in nature of work activities and traditions in work settings might, for example, explain why the pedagogic strategies of the supervisors in the physiotherapists private practice were primarily based on role modelling (Figure 3(A)) whereas the pedagogic strategies of the supervisors in the hospitals and psychiatric care institution were mainly based on trust (Figure 3(C)). Furthermore, nursing home and home-based care supervision was based on letting go (Figure 3(D)) and supervisors maintained more distance from the students’ daily practice. Indeed, in line with previous research (Goller et al. 2019), we recognise how supervision in home-based care follows traditions and supervisors’ inherent values to support students in such a way that they fully contribute as new team members to the work in the shortest time frame possible. Therefore, the traditions of professions and the pedagogical values and norms in work settings seem to determine, at least partly, the variation in workplace supervision (Lave and Wenger 1991; Morris et al. 2021).

Another noticeable finding of our study is that supervisors seem to be continuously engaged in a balancing act. They are challenged to balance the interests of the patient, the student, the supervisor’s own interest and the interest of the school or organisation. For example, some supervisors would like to approach their students as equal colleagues; however, they struggle because the student is still learning the job. Furthermore, they would like to stimulate the student to work individually and independently, but they cannot, because that is not always in the best interests of their patient.

With regard to this balancing act, previous research has indicated that decisions about how far to trust students to carry out patient care on their own, seems related to the relationship between supervisor and student. Indeed, we recognise in our findings that getting along of supervisors and students could benefit a successful supervision relationship (Sagasser et al. 2017; Heyns et al. 2019). Trust seems to foster supervisors’ pedagogic strategies that are aimed at optimising possibilities for students to actively participate in daily work activities. Although students’ and supervisors’ ability to get along is mainly a positive aspect in workplace supervision, it could also come with potential risks. It may, for example, also lead to overestimation of students’ performance (Barnhoorn et al. 2023). On the other hand, when supervisors have less confidence in the student, they should be careful to not place students in a passive role (Geitz et al. 2016). Further research is recommended to investigate how students’ learning process is shaped in the social relationships with supervisors in different work settings.

Limitation and further research

An important limitation of our study is that the supervisor interviews provided us with a rich data set, but gave us little insight into the learning process of students. Including students’ perspectives would have provided us with more in-depth information regarding the interrelatedness of supervisors’ pedagogic strategies and students’ learning experiences. Future research should clarify how the configurations of supervisors’ pedagogic strategies are associated with students’ learning at the workplace.

Implications for practice

Our study presents new ways to frame workplace supervision from a focus on demonstration, stimulated participation and entrustment. This study serves as a template for supervisors and educators when reflecting on the supervision of students’ workplace learning. More specifically, the configurations of pedagogic strategies based on (A) role modelling, (B) overall support, (C) trust, or (D) letting go, elicit reflection for enactment and improvement of workplace supervision.

Ethical approval

The research ethics committee of the Open University approved our research design from ethical review (U2019/01871/MQF).

Acknowledgement

The authors would like to thank the supervisors, students, and co-workers who participated in this study, and the work settings for enabling data collection.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Funding

The authors reported there is no funding associated with the work featured in this article.

Notes on contributors

Lieke Ceelen

Lieke Ceelen, MSc, is a PhD candidate on workplace learning and supervision.

Anne Khaled

Anne Khaled, PhD., is a senior researcher in educational sciences, who investigates student learning, educator pedagogies and professionalization in relation to responsive vocational and professional education.

Loek Nieuwenhuis

Loek Nieuwenhuis, PhD, is an emeritus professor and conducts research on learning and working, with a particular emphasis on the expertise of educators.

Elly de Bruijn

Elly de Bruijn, PhD, is a professor with a special interest in the processes of becoming and developing a vocation, and how affordances and interaction can enhance these processes.

All authors are specialists in research on teaching and learning processes.