Students in interprofessional clinical placements: How supervision facilitates patient-centeredness in collaborative learning

ABSTRACT

The patient’s role in interprofessional education is fundamental; however, it has received insufficient attention. This study explores how supervision facilitates and supports undergraduate students’ learning of patient-centeredness in interprofessional clinical placements. Data were generated in three clinical contexts based on a focused ethnography approach. We found that supervisors are engaged in student teams’ interprofessional learning, but often in their preparations or debriefings and seldom during patient encounters. The patient perspective is also less frequently scrutinized in planned interprofessional supervision sessions. Nevertheless, clinical settings provide numerous opportunities that may be exploited further.

KEYWORDS:

• Clinical supervision
• interprofessional education
• patient-centered care
• health occupations students
• medical students

Introduction

Interprofessional education (IPE) occurs when “students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes” (World Health Organization WHO, 2010, p. 10). Learning outcomes from IPE are often considered generic or “soft” (Thistlethwaite & Moran, 2010) and comprise skills, attitudes, and knowledge applicable to all health professions. Students are expected to learn about professional roles, teamwork, and communication. The patient is central to the learning process (Thistlethwaite & Moran, 2010). Patient-centeredness implies that students learn to perform their work by including the patient in the team, striving to understand the patient’s perspective, and recognizing patient needs while working in his or her best interest and ensuring patient safety (Thistlethwaite & Moran, 2010. Competency frameworks such as the IPEC Core Competencies (Interprofessional Education Collaborative Expert Panel, 2016) suggest patient-centeredness as an overarching feature of these core competencies.¹ Not only is patient-centered care optimal, but it also resonates with legislation in countries such as Norway, Sweden, and the United Kingdom, where patients and service users are entitled to be involved in decisions concerning their health and well-being (Government of the United Kingdom, 2012, The Norwegian Ministry of Health and Care Services, 1999, The Swedish Ministry of Health and Social Affairs, 2014).

Clinical placements for interprofessional students are ideal for learning collaborative practice with the patient (Hilton & Morris, 2001). Bleakley and Bligh (2008) suggested that clinical learning should happen with and from patients and that students can only learn patient-centeredness with the patient, not through educators. The role here for educators is instead to facilitate this learning. Further, Bleakley (2014) encouraged interprofessional learning comprising “learning to think (with) patients in mind” (p. 13).

Hence, supervision is central in interprofessional clinical contexts, and the supervisor plays a critical role both for undergraduates (Ericson et al., 2012) and for health practitioners (Davys et al., 2021). Many terms, including mentor, facilitator, clinical teacher, clinical supervisor, and placement teacher, are used interchangeably for the same role (Marshall & Gordon, 2005). In this paper, we use “supervisor” to refer to one or several persons (often clinicians) who serve as facilitators and supporters for interprofessional student teams in their clinical placement. In an interprofessional context, the supervisor can have a different professional background than many of the student team members. Interprofessional supervisors focus on facilitating how students learn with, from, and about each other rather than profession-specific content (Davys et al., 2021). Interprofessional supervision can include reflection on aspects such as roles in the team, responsibilities, interprofessional communication, and (shared) values (Interprofessional Education Collaborative Expert Panel, 2016).

Clinical or professional supervision encompasses the formal supervision of qualified health practitioners through intensive relationship-based education and training that are case-focused and support, direct, and guide supervisees’ work (Milne, 2007). Supervision can be considered an intersubjective mutual dialogue, where the supervisor and supervisee construct the agenda together (Herron & Teitelbaum, 2001). In professional supervision, supervisors and supervisees often share professional backgrounds, which may not be the case in interprofessional contexts (Davys et al., 2021). Due to different backgrounds, the different experiences in providing and participating in supervision activities of supervisors and supervisees add to the complexity (Davys et al., 2021). Nevertheless, supervision in interprofessional contexts can also be considered a formal, relational, and case-focused activity (Milne, 2007), which implies a cognitive, constructive, and collaborative process between the supervisor and supervisee (Herron & Teitelbaum, 2001). Norwegian scholar Sidsel Tveiten (2019) described supervision as a spontaneous and integrated part of everyday practice or a planned and structured event with an essential relational aspect. This description applies to professional and interprofessional supervision (Tveiten, 2019), even if the content of the supervision may differ.

In previous research, the experience of supervising interprofessional student teams shows that it can be challenging to focus on the interprofessional aspects of a placement (Chipchase et al., 2012, O’Leary et al., 2019). Furthermore, supervisors’ own experiences with and attitudes toward interprofessional practice and how this impacts supervision and the initiation of formal and informal learning opportunities and activities have been elucidated (Marshall & Gordon, 2010, Reeves et al., 2016). Researchers have provided insight into how the specialized preparation and training of interprofessional supervisors are critical to their becoming more comfortable in their role (Kristensen & Flo, 2014, O’Brien et al., 2019, O’Leary et al., 2019, Yang et al., 2017), as well as the ability of preparation to promote more positive student outcomes (Kent et al., 2017). Although some studies have addressed patients’ essential role in collaborative practice learning (Marshall & Gordon, 2005, 2010), few have provided insight into patients’ roles and perspectives in interprofessional learning activities and supervision. Echoing O’Leary et al. (2019) and Reeves et al. (2016), Jensen et al. (2022a) argued that the patient’s role has been insufficiently articulated in research on IPE for undergraduates in clinical placements and that this topic needs further exploration.

Therefore, this study aimed to understand better how supervision facilitates and supports undergraduate students’ learning of patient-centeredness in interprofessional clinical placements.

Theoretical underpinnings

This study draws on concepts from Erving Goffman’s dramaturgical analysis. Goffman (1990) used the (social) stage as a metaphor to understand how different persons act and interact in everyday life, which he calls performance. According to Goffman (1990), humans assume different roles depending on the context. People strive to be perceived as likable in their various roles and to fulfill expectations. When roles deviate from expectations, it may be difficult to properly play one’s role.

Goffman (1990) distinguishes between being frontstage, which entails performing for an audience (of at least one other person), and backstage, where performers can withdraw from the public gaze. Individuals perform frontstage daily when interacting with others in different settings. However, it is only when someone withdraws backstage that they can be honest and show who they are (Goffman, 1990). In his work, Goffman (1990) exemplified several cases where there is a clear distinction between the interaction (attitude, language, manners, etc.) backstage and frontstage. He illustrated how people can transition backstage to frontstage in seconds and “mask up” for their audience.

Interprofessional clinical placements involve multiple actors and entail a complex performance in which each actor has a frontstage and backstage, and the team has a common frontstage and backstage. For students, the frontstage corresponds to encounters between student teams and patients. The backstage corresponds to moments when student teams are withdrawn, such as in their working area (nurse station, meeting rooms, etc.) or informal settings such as breaks. For supervisors, the frontstage corresponds to occasions where they interact with individual students or student teams, and backstage corresponds to moments when they are withdrawn, for example, in their office. The patient’s frontstage corresponds to their performance in front of students and health practitioners in a healthcare context, and backstage is the designated room in which they can relax, for example.

Goffman´s theory of backstage and frontstage regions, and interaction in these, offers a new perspective on undergraduates’ interprofessional learning in clinical placements. In this study, the theory is applied to identify where interprofessional supervision in clinical contexts happens, what roles the supervisors fill, and how their role is enacted.

Methodology

This study is part of a Nordic research collaboration between UiT The Arctic University of Norway and Linköping University in Sweden through the project, “Collaborating to learn and learning to collaborate: Interprofessional education of health professionals for the 21st century.” The project aims to explore IPE in clinical placements.

This study is positioned within a social constructionist perspective where “the world is produced and understood through interchanges between people and shared objects and activities” (Savin-Baden & Major, 2013, p. 62). A social constructionist position aligns with Goffman´s dramaturgical analysis, where micro-social interaction is emphasized. The micro-social interactions imply that meaning is constructed in everyday life through the individuals´ interaction. Moreover, the study adopted a focused ethnographic approach (Andreassen et al., 2020) which is pragmatic and suitable for research on health care (Higginbottom et al., 2013) and health professions education (Andreassen et al., 2020). Topics in the research are often pre-selected, and fieldwork is conducted within a particular timeframe or localized to an event (Higginbottom et al., 2013).

We also consider the study a collective case study (Kekeya, 2021). Kekeya (2021) synthesized some of the literature on case studies and highlighted that “a collective case study includes multiple case studies, which are undertaken in one or single research, to gain in-depth insight of the research topic” (Kekeya, 2021, p. 35). In this study, two researchers generated data using multiple methods, including participant observation, semi-structured interviews, and informal conversations with interprofessional students, their supervisors, and patients in three contexts. Fieldwork began in February 2020 and concluded in September/October 2021. Data were subsequently analyzed within and across cases to understand patient-centeredness in the supervision of interprofessional students (Kekeya, 2021).

Study contexts

The study contexts were a Norwegian community health center (“the health center”), a Norwegian rehabilitation facility (“the rehab”), and a Swedish interprofessional training ward (“the IPTW”).

The health center provides intermediate care, mainly for older patients with complex health issues. Patients are admitted from a regional hospital or their homes, and plan to return home or proceed to long-term care in a nursing home. Multiple student teams oversaw 2–3 patients’ daily follow-ups in the health center during placements.

The rehab provides specialized interprofessional rehabilitation of patients with complex functional impairment following illness or injury. During the placement, the student team oversaw the daily follow-up of two patients in the rehabilitation hospital.

The IPTW is located within an orthopedic hospital ward providing pre-and postoperative patient care. Student teams oversaw a variation of six patients during their placements in the IPTW, both admitting and discharging patients.

Students in the health center and the rehab had their interprofessional placements as a part of their profession-specific training at that institution. The clinical placement in the IPTW was a mandatory, standalone two-week rotation for all health profession students at the university. For an overview of the contexts, see Table 1.

Table 1. A comprehensive overview of the contexts.

Contexts	The health center (Norway)	The rehab (Norway)	The IPTW (Sweden)
Length	2–4 days (day shifts)	5 days (day shifts)	2 weeks (day and night shifts)
Instructions for students	Engage in interprofessional collaboration when encountering, performing daily follow-up with, and providing care for patients in the ward. Keep an interprofessional journal, including observations and suggestions for further care.	Engage in interprofessional collaboration according to the detailed timetable (showing a variety of activities for students to undertake, e.g., physiotherapy sessions, morning routines, etc.).	Work as part of an interprofessional student team to oversee the daily care, mobilization, and rehabilitation of patients. Daily holding points are displayed on a timetable, including morning routines, rounds, patient meals, supervision, lunchtime, etc.
Participating students’ professions	Final-year students from: Nursing (n = 17) Medicine (n = 5) Physiotherapy (n = 3) Occupational therapy (n = 1) Pharmacy (n = 6)	Second- and final-year students from: Nursing (2^nd year) (n = 3) Occupational therapy (n = 1) Physiotherapy (n = 1)	Final-year students from: Nursing (n = 5) Medicine (n = 3) Occupational therapy (n = 1) Physiotherapy (n = 1)
Team size	5–6 students	5 students	5–6 students
Participating supervisors’ professions	Registered nurse (n = 4) Medical doctor (n = 1) Physiotherapist (n = 1) Pharmacist (n = 1)	Registered nurse (n = 1) Physiotherapist (n = 2) Occupational therapist (n = 1)	Registered nurse (n = 3) Medical doctor (n = 1) Physiotherapist (n = 1) Occupational therapist (n = 1)
Structure ofinterprofessional supervision	Scheduled time for interprofessional reflection (reflection hour; 1–2 h each period)	Scheduled interprofessional supervision (3 1-hour sessions)	Scheduled time for interprofessional reflection (1–2 h at the end of the day shift)

The supervisors in two contexts were clinicians responsible for supervising students on their profession and interprofessional teams. On a day-to-day basis, these supervisors provide healthcare and treatment and, in periods with student placements, they supervise students. Supervision is considered part of their job description regardless of their professional background.

In the third context, the supervisor was a health professional who did not have a clinical position but an executive function for students in clinical placements.

In the different contexts the supervision was conducted with slight variation in structure (see Table 1). Supervision was set to include facilitation of students learning with, from and about each other in groups.

Participants and recruitment

Study participants were recruited via purposeful sampling (Patton, 2002). On-site personnel supported recruitment by providing oral and written information about the study to patients, students, and staff before the placements started. Posters were hung in the wards to inform others of the researcher’s presence and agenda. When meeting participants in person, this information was repeated.

In total, 47 students, 19 supervisors, and 6 patients (two in each context) gave their written consent to participate in the study. The student participants were mainly final-year students and had completed multiple previous profession-specific placements in hospitals and communities.

All participants were recruited for participant observation, but a sample was invited to give interviews in the two Norwegian contexts. Where there were multiple teams, a selection of students was invited. We aimed for heterogeneous groups representing several professional perspectives and a broad experience base (Krueger & Casey, 2015). Thus, the selection was performed such that variation in professions, team affiliation, and, to the extent possible, gender could be attained. Ultimately, the interviewees were 12 students from the health center and 4 from the rehab. All participating supervisors in the Norwegian context were invited to join the group interviews, and three from each accepted the invitation.

A study regarding the interaction between the participating students and patients was published elsewhere (Jensen et al., 2022b).

Empirical studies

Participant observation

The first author (CBJ, RN, Ph.D. student) conducted participant observations at the health center and the rehab, and coauthor Tove Törnqvist (TT, Registered OT, Ph.D. student) conducted observations at the IPTW. Observations included student team meetings, interaction among team members, supervisors’ interaction with student teams, and supervision sessions. An example of the observation protocol from the Norwegian context is provided in Appendix A.

The health center observations were conducted in two separate periods with multiple student teams (two and three teams). CBJ rotated to the different teams’ meetings as they prepared for patient encounters, undertook patient encounters, or during debriefing afterward. At the rehab, observation occurred in the patient´s room or physiotherapy or occupational therapy facilities. Meetings exclusively with students and interaction between the students and the supervisors were observed. At the IPTW, TT alternated between day and night shifts. Observations occurred at the nurse station and during rounds and other scheduled meetings.

Jot notes were written during or immediately following participant observations. Depending on the situation, some notes focused on actions and interactions, while others referred to participant dialogue. Jottings were rewritten as comprehensive field notes after fieldwork (Emerson et al., 2011).

Qualitative interviews and informal conversations

Qualitative interviews were conducted face-to-face or on Microsoft Teams in the Norwegian context. We intended to interview one group of students and one group of supervisors per fieldwork session. In the second fieldwork session at the health center, a formal interview with the supervisors was hindered; nevertheless, informal conversations were held throughout the period. Focus group interviews (Krueger & Casey, 2015) inspired the interviews. Interview guides comprising open-ended questions were developed to indicate the themes of interest (Appendix B). Data from the observations were the basis of the interview questions. CBJ moderated the interviews, with coauthor Anita Iversen (AI) as a co-moderator. The interviews were transcribed verbatim.

At the IPTW, TT had informal conversations with the participants when appropriate and invited them to elaborate on their perceptions of the clinical placement and their interactions with other team members, supervisors, and patients. Summary notes were then written.

Data analysis

CBJ performed a five-step reflexive thematic analysis (TA) (Braun & Clarke, 2022). A TA provides the flexibility to capture both semantic and latent patterns in the data. This supported exploration of how interprofessional supervision is enacted in different contexts and how the patient perspective is thematized in the supervision sessions.

Data were imported into NVivo (QSR International, 1999). In step one, CBJ immersed in the data by transcribing and re-reading the field notes. The first impression of the data was discussed with the research team. Further, codes were generated through a combination of data-derived (semantic) and researcher-derived (latent) codes (Braun & Clarke, 2013, 2020, 2022). Single words, sentences, or sections in the interview transcriptions or field notes were the units of analysis. The coding of the interview data was mainly semantic, while the coding of the field notes was mainly latent.

Nevertheless, the field notes that cited dialogue between the supervisors and students were coded semantically using participants’ own words. After coding the entire dataset, the focus was narrowed to supervisors’ interactions with students and patients. Themes were developed creatively, alternating between codes and themes. Also, we alternated between mind maps to illustrate relationships between themes and written text. Proposed themes were scrutinized, revised, and refined in research team meetings. The analysis generated three themes: alternating roles, presence, and positioning; illuminating interprofessional learning opportunities; and giving trust and independence.

In the data generation and analysis process, the research team scrutinized CBJ´s positioning considering her professional background and experience in supervision in education and clinical settings. Such a reflexive process was carried out throughout the project. Reflexivity concerns turning the lens toward oneself as a researcher, which is essential in qualitative research to understand the researcher’s role in generating knowledge (Berger, 2013). The interprofessional composition of the research team promoted multiple perspectives and thus supported critical views of the data analysis by discussing the underlying potential expectations during the data analysis processes. The research team members have various experiences with interprofessional teams and teamwork as clinicians, lecturers, and researchers.

Ethics

The Norwegian Centre for Research Data (no. 831589) and The Swedish Ethical Review Authority (no. 2018/46–31) approved the study. All data were collected following the Helsinki Declaration and Ethical Guidelines for Educational Research (British Educational Research Association, 2018). Participants provided their written consent before data collection and could withdraw from the study at any time.

Results

In the following subsections, the three themes generated through the reflexive TA will be presented with empirical examples and interpreted through the lens of Goffman’s dramaturgy.

Alternating roles, presence, and positioning

Supervisors in two of the three contexts moved in and out of the student teams backstage. At the IPTW, this movement happened in and out of the nurse station and in patient rooms, entailing supervisors working in proximity to the students and patients. Hence, supervisors were available throughout the day, and students actively approached them with concrete questions regarding theoretical and practical issues. However, students rarely asked questions about collaboration and teamwork. Supervisors also moved in and out of the students’ designated work area at the health center, but kept a low profile when entering and leaving. Specifically, they sometimes whispered to each other if more than one supervisor was present. Here, supervisors observed and listened to student teams’ conversations from a distance, such as while sitting behind team members.

When supervisors were present with the student teams, it led to reciprocal communication, as the students approached supervisors with questions and vice versa. Nevertheless, the interprofessional supervisor was only present with the team at scheduled times at the rehab and did not come and go, as in the other contexts. At the rehab, supervisors did not observe or approach teams unannounced.

Supervisors’ frontstage presence varied across all contexts. At the health center, two occasions where a supervisor joined the student team when encountering a patient were observed. On the first occasion, the supervisor introduced the students to the patient and then left the room. On the second occasion, the supervisor was present to ensure proper handling of a medical device the patient needed. Both cases, then, were about patient safety issues.

Supervisors in the Norwegian context did not interact with patients or observe student teams interacting with patients frontstage. In contrast, supervisors at the IPTW were always present during the day and evening shifts. Their presence was characterized by working shoulder-to-shoulder with the student teams and knowing about and building relations with students and patients. On several occasions, students approached the supervisors with specific patient problems, and the supervisor responded immediately, sometimes going frontstage to interact with patients alongside the students. At the IPTW, students were not explicitly instructed to interact with patients in teams; thus, on many occasions, students met with patients individually.

Besides varying their presence, supervisors also changed roles depending on the agenda and learning activity. For example, a supervisor at the IPTW changed roles every few hours: acting as a colleague during morning routines, serving as a background observer during rounds, and presiding over students’ reflections in the afternoon. Supervisors at the health center alternated between observing, giving comments and reminders from the background, and presiding over supervision sessions. The rehab was unique in that the supervisor mainly had the established role of leading the interprofessional supervision sessions.

Illuminating interprofessional learning opportunities

Across all contexts, supervisors highlighted opportunities for students to share learning experiences. This happened backstage through questioning, exemplifying, and facilitating activities that students could accomplish together with patients frontstage. Supervisors supported student teams using questions and comments with various characteristics, including those concerning the patient, process, and theory or students’ knowledge.

Patient-related questions were generic, for example, “What is it like to be a patient for a day?” Some were specific to a patient, such as “Have you asked her what she wants?” Some patient-related questions also concerned students’ knowledge of a particular treatment; for instance, a supervisor said: “I ask out of curiosity, has anyone tried to find out why the patient is itching? Maybe you could involve the pharmacy student from the other team?” Some questions were merely theoretical and made students explicate professional theoretical knowledge for their peers; for example, when a supervisor in the health center asked a pharmacy student about the contraindications of a drug prescribed for a patient during a patient’s medication reviewconducted in one of the student teams.

Across all contexts, teams were supervised on their teamwork and process; however, they were not always given cues or reminders to consider regarding the patient’s situation. At the health center, this happened while teams were working together to prepare or during post-encounter meetings and planned supervision sessions. The example below shows how a supervisor at the health center tried to facilitate reflection in a student team on their work process to stimulate interprofessional collaboration among the students.

A team comprising three nursing students, two pharmacy students, and a medical student was assessing one of their patient’s health issues. The team decided to split up to work on different tasks; the nursing students met with the patient while the other students remained at their workstations to peruse the electronic health record (EHR). After returning from seeing the patient, the three nursing students sat together discussing the encounter and reading the EHR on a widescreen. The medical and pharmacy students were working on three computers facing away from the nursing students.

The supervisor entered the room and immediately reacted upon seeing the students. Standing between the students, she asked them to kindly stop what they are doing and said in a calm and curious tone, “Can you tell me what I am looking at right now?” The pharmacy and medical students turned around and replied, “We have split up. We are perusing the information from each profession’s point of view.” The IP supervisor responded, “How about processing this information together?” Before anyone answered, she continued by giving an example of the difference between multidisciplinary and interprofessional collaboration: “What does it take to have good interprofessional collaboration versus multidisciplinary work? Is this what is happening here now? You are sitting in the same room, but are you taking advantage of that?”

At the rehab, the student team spent most of their time working with each other and with patients without supervisors present. This resulted in less frequent support or interruptions to their backstage teamwork and frontstage interaction with patients.

Another aspect of illuminating interprofessional learning became apparent through observation of planned and structured supervision sessions across all contexts. In two contexts, supervisors who led the interprofessional supervision sessions reported having a “cheat sheet” with predetermined questions that pinpointed conversation topics, including student experiences such as patient encounters and teamwork. Supervisors acknowledged students’ statements regarding different issues but only occasionally scrutinized them further. On one occasion, a student team initiated a discussion about patient issues. The supervisor asked them “to move the focus from the patient to themselves,” a direction with which the students complied. Also, many observed sessions were characterized by turn-taking, where students spoke in turns, often about their different roles and how they could learn from each other, but seldom about their encounters with patients.

Facilitating trust and independence

The final theme describes how supervisors trust student teams in patient interaction and how independent teamwork is essential in these interprofessional clinical learning arrangements.

Independence was an underlying principle across all contexts. Supervisors seemed to expect students to handle frontstage performances with patients independently; hence, supervisors did not need to play a role in this performance. Supervisors trusted students to make independent professional choices regarding the measures and actions in the patients’ interest.

Across all contexts, supervisors emphasized how student teams were allowed to work toward a joint decision regarding patients. One supervisor said that it is necessary “to manage to sit on one’s hands,” elaborating that supervisors often feel the urge to help student teams by providing answers and suggestions regarding their plans and actions involving patients frontstage, but actively refrain from intervening to allow the team to generate their own course of action. The supervisor explained: “Several times this morning, I wanted to say, ‘Have you thought about this or that?’ but they eventually reach an answer, even if it takes a while […].” Another supervisor agreed, stating as follows:

Today, they [the student team] were going to see a patient with cognitive impairment, and my immediate thought was, “Oh, the whole team should not go in,” but I managed to hold back while they discussed and shared a bit about what a cognitive impairment is. They eventually realized after a while that only two [students] should see that patient. Then, I realized that teams would eventually find the answer, but I want to ensure they get there, and I may have to intervene as a supervisor if I see that they don’t. It was an excellent experience for me. [to see that they did]

Both excerpts show how supervisors suppressed their immediate instinct to guide student teams with questions and comments in favor of letting the students play leading roles in their teamwork.

As mentioned, in two of the three contexts, supervisors did not observe or assume a role frontstage; instead, they oversaw the student teams’ preparations and finishing work and received briefings in supervision sessions on how the team interacted with patients. Several students recognized the principle of becoming independent, but sometimes missed the supervisor’s presence in patient encounters frontstage and when working backstage with the student team. According to a medical student at the health center,

We were a large team in the patient room, but if a supervisor had been present, they could have given us some feedback, which would have been helpful. Because we don’t know, I mean, the patient seemed positive and happy, but it would be nice if someone with an outsider’s perspective had observed the encounter.

A nursing student at the rehab commented as follows regarding backstage preparations before meeting a patient for the first time:

I almost felt a kind of lack of a supervisor or [a] superior, not management, but someone who has some idea of what we are meant to do. I somehow did not quite know what it was, what the intention was, so we had to find out a bit of it ourselves together […] We did not get any feedback on whether it [the preparations, interactions with patients, etc.] was done right, so that caused some uncertainty (laughs a little).

Despite these experiences, none of the students expressed these feelings to the supervisors during the interprofessional supervision sessions or on other occasions that involved interacting with supervisors. Moreover, the supervisors did not ask about students’ thoughts.

Discussion

In this study, we aimed to understand better how supervision facilitates and supports undergraduate students’ learning of patient-centeredness in interprofessional clinical placements. Our findings are diverse, but tell an overarching story of when, when not, and how the patient was involved. In the study context, a patient focus was integrated into some interprofessional supervision; for example, supervisors asked the student teams about specific patients´ health issues and how the team members would resolve them. The interaction between student teams and supervisors seemed to center around practical issues or competencies such as understanding each other’s roles, team collaboration, and work processes. Looking at the findings through Goffman’s (1990) lens, it was unexpected that supervisors mainly situated themselves with student teams backstage.

Integrated and spontaneous supervision, following Tveiten’s (2019) definition, occurred when supervisors were present with the interprofessional student teams during preparation or when processing patient encounters. Here, supervisors’ presence facilitated reciprocal dialogue characterized by questions and reminding comments and cues. The conversation was on one hand based on what are considered core competencies in interprofessional education, for instance, the domains Interprofessional Education Collaborative Expert Panel (2016) proposed. On the other, students approached supervisors with many practical issues related to pending patient procedures or about where to find appropriate equipment. Few, if any, questions were identified that were rooted in interprofessional core competencies or considerations regarding student teamwork or teams’ encounters with patients.

The terms “reflection” or “reflection hour” were used in the student schedules to denote supervisors’ conversations with them in two of the contexts, the health center and IPTW, respectively (see Table 1). Reflection aims to return to an experience or event and think about and analyze it to develop competencies and future practice (Schön, 1987). The supervisors in our study seemed to consider reflection a central part of their supervision of students. Davys et al. (2021) supported this, confirming that supervisors emphasized reflective learning models in interprofessional supervision and considered it more important to use such an approach when dealing with various professional backgrounds. The supervisors in this study seemed to consider incorporating reflective approaches in interprofessional clinical placements as meaningful, for example, through their questions or prompts. Nevertheless, the planned interprofessional supervision sessions across contexts were characterized by turn-taking, which aimed to include everyone and ensure that each person had the chance to participate. This method may help supervisors decide which path to follow in subsequent supervision (Tveiten, 2019). However, across the cases in our study, a fresh round often continued with a new question from the agenda and thus did not inform a specific supervision direction. Our findings showed few instances of deep exploration of students’ issues; although supervisors acknowledged what was said, they did not scrutinize the content. Even when students were explicitly invited to reflect on their experiences after a shift, there were few cases of a true exploration of what was said and how related matters affected student team members’ interactions with each other and patients.

Supervisors’ frontstage presence was rare in two of the contexts examined in this study, and what happened in patient encounters went unthematized in many of the planned supervision sessions. Our findings suggest that supervisors’ frontstage presence was related to patient safety issues and not focused on gaining insight into the student teams´ interaction with that patient. Not only did this approach reduce insight into what happened in each interaction, it also limited the chance for feedback to individual students and student teams. Some students reported missing the supervisor’s presence and opportunity for feedback and support on their team’s interaction with patients. Considering the apparent differences in performance backstage and frontstage that Goffman (1990) observed, more supervisor presence frontstage might benefit the supervision process and provide a better basis for planned interprofessional supervision and feedback to students.

Supervisors talked about “sitting on their hands” as a strategy that could be a way to endow the student teams with trust and encourage independence, thereby facilitating greater student ownership in frontstage performance. In agreement, Ericson et al. (2012) also reported students’ positive perceptions of being autonomous and taking an active role with patients. Claeys et al. (2022) noted that interprofessional students need to balance autonomy and supervisory support, while Ramani and Leinster (2008) underlined that directly observing the learner – patient interaction is “very illuminating” (p. 353) and helpful in planning future learning activities. The latter also emphasized that directly observing students is crucial to giving appropriate feedback (Ramani & Leinster, 2008). Feedback can be highly beneficial to students, as it can help them better understand their performance, why they may have performed in a certain way, and how they can improve (Wisniewski et al., 2020). However, research on feedback in interprofessional contexts is limited (Tielemans et al., 2021).

The supervisors’ emphasis on backstage presence in interprofessional placements partly aligns with Bleakley and Bligh (2008), who called for medical educators to assume a more withdrawn and facilitating role. However, it is unclear whether Bleakley and Bligh’s (2008) suggestion of stepping aside was meant to be taken literally to the extent identified in our data. Supervisor presence during students’ interprofessional collaboration in patient encounters can promote learning aspects related to patient-centeredness and the core competencies students are expected to develop (Conte et al., 2022).

Cheema et al. (2022) addressed issues related to the supervision of medical students and influence of patient presence in supervision sessions on students and supervisors’ patient-centeredness, for instance, how they speak about the patient. Those scholars also referenced the backstage and frontstage (Goffman, 1990) in the discussion of their findings, especially role disturbance due to patient presence in areas previously reserved for supervisors and students. Like in the interprofessional placements, the supervisor was not present with students during the initial patient encounter (Cheema et al., 2022). Traditionally, students’ backstage is the exclusive locale of supervision. However, backstage becomes frontstage when the patient is present and, as such, another location where students must perform.

Students and supervisors have perceived patient presence as challenging, but patients have reported that it helped them better understand their diagnosis and health issues. Patients felt empowered to correct students’ perceptions of issues raised during encounters (Cheema et al., 2022). Patient- and family-centeredness are emphasized in supervising and supporting collaborative learning (Marshall & Gordon, 2005, 2010), but interprofessional supervision is complex and challenging (Marshall & Gordon, 2005, Reeves et al., 2016). Even if learning about and improving collaboration in patients’ interests (Marshall & Gordon, 2005) are the main focus, it may be a giant leap––at this point––to include the patient in supervision sessions, as also found in Cheema et al. (2022). As interprofessional researchers and educators, we propose starting with an enhanced and more conscious patient focus in dialogue and reflections in integrated and planned supervision. Hence, the patient perspective will constitute the basis for interprofessional learning in clinical settings, and the potential for enhancing patient-centeredness in IPE can be realized.

Across the contexts in our study, supervisors in interprofessional clinical placements enabled students to learn with, from, and about each other. Our findings suggest that supervisors competently support students in identifying how this happens in their interactions, demonstrating supervisors’ awareness of the definition of IPE. However, patients’ unique perspective on what good quality of care and services entail is less scrutinized. Moreover, across all contexts, the organization of the placements provides multiple opportunities for dialoguing about and exploring interprofessional (student) teams’ experiences with patients. The organization of predetermined questions may hinder supervisors from delving into a spontaneous dialogue about the students’ experience with patient encounters and, to use a metaphor, may thus imprison supervisors within the confines of the agenda.

The interprofessional clinical placements observed can be gold mines for authentic interprofessional collaboration learning with patients as a starting point. The supervisors in our study facilitated and supported student learning with, from, and about each other. However, the patient-centered focus was casual and did not permeate discussions on other core competency aspects. Davys et al. (2021) emphasized how supervisors’ practice is shaped by their own experiences of being supervised (Davys et al., 2021). This study, however, does not explore how each supervisor perceived supervision as a phenomenon. Thus, we know little about their experiences of being supervised and how this emerged in their approach to interprofessional students.

Although the findings given in this paper are reported by distinguishing between or connecting different contexts, an explicit discussion on how contextual factors influence supervision in interprofessional contexts needs to be performed. Some of our findings suggest that the context in which supervision is enacted influences how and when supervision occurs (or does not) and how the patient-centered focus is included. A greater focus on the context in future studies could generate informative findings that further account for the impact of context on supervision and the facilitation of patient-centeredness.

Strengths and limitations

It is essential to highlight that this is a study of undergraduate health professions students in two high-income Scandinavian countries with well-adapted welfare systems. Therefore, the transferability to other contexts must be carefully considered.

By generating data in various contexts, we adopted a holistic focus to capture the complexity of our observations. In this study, supervisors’ actions and interactions were considered part of the big picture. A holistic focus may be a strength, as supervisors’ practice could be considered organic and naturally enacted with student teams. However, in the IPTW, we were unable to observe frontstage actions because of COVID−19 restrictions. Future research on IPTWs would help provide more insight into this scenario.

It can be considered both a strength and a weakness that not all authors had first-hand knowledge of the data and the different contexts, as only one researcher in each context generated data. However, the research team extensively discussed data generation, analysis, and possible interpretations. The different perspectives and combination of the researchers’ insider and outsider perspectives are considered essential to the quality of the study.

Given the focus of this paper––how supervisors facilitate undergraduate students´ learning of patient-centeredness––another limitation is the lack of involvement of patients, for example, as contributors in designing the study or as co-researchers.

We acknowledge that the study’s data generation, analysis, and reporting is a social construct and may have differed if other researchers were to conduct a similar study in the same context. Using data from different contexts, the culture incorporated in each context may have influenced the results generated in this study. Hence, the transferability of our findings to similar contexts must be handled cautiously.

Conclusion

Notwithstanding these limitations, this study highlights when, when not, and how supervisors in different Nordic contexts support student learning in interprofessional clinical placements and how they include the patient in their supervision practice. Our study shows that supervisors are excelling at highlighting the teamwork aspect of interprofessional student teams, but may benefit from more explicit awareness of the patient-centered part. By doing so, they can support and facilitate students’ learning and enactment of patient-centered care in interprofessional care provision.

Acknowledgments

We want to thank all students, supervisors, and patients in the two Norwegian healthcare institutions and the Swedish Interprofessional Training Ward that made this study possible through their participation.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This study was funded by UiT The Arctic University of Norway (CBJ) and the Swedish Research Council (TT) [2017-034699]. The funding institutions did not influence the research.

Notes on contributors

Catrine Buck Jensen

Catrine Buck Jensen is a Registered Nurse with a master’s degree in education and is currently a Ph.D. student in Health Sciences at UiT The Arctic University of Norway. A major theme of her Doctoral work is the patient’s role in interprofessional education in clinical settings and specifically how the patient is included when undergraduate students learn interprofessional competencies. Catrine has contributed several book chapters in Norwegian anthologies on supervision and higher education, and the supervision of nursing students was the major theme of her master’s thesis.

Bente Norbye

Bente Norbye is a Professor at UiT The Arctic University of Norway and the head of the research group Health Professional Education. A major theme of her scholarship has been researching higher health education (e.g., interprofessional education in students’ clinical placements, flexible and blended learning facilitation for students living in rural areas, and northern nursing education for students living in rural and indigenous communities). Bente explores collaborative practices using Action Research methodology to make research contributions relevant to healthcare practice, and health professional education.

Madeleine Abrandt Dahlgren

Madeleine Abrandt Dahlgren is a Subject Representative and Research Leader for the Medical Education Research Group at Linköping University since 2012 and an Adjunct Professor at the Centre for Faculty Development at The Faculty of Health Sciences, UiT The Arctic University of Norway. Madeleine has published widely within the field of higher education, particularly regarding the relationship between professional/higher education and professional work.

Tove Törnqvist

Tove Törnqvist is an Occupational Therapist and Ph.D. in Medical Education at Linköping University. Her doctoral project focused on students’ interprofessional learning in different practices. She collected data through ethnographic observational studies using a research design influenced by Practice Theory.

Anita Iversen

Anita Iversen is an Associate Professor at UiT The Arctic University of Norway. Her areas of interest in health professions education research and innovation are supervision, interprofessional education, collaborative practice, teaching, and learning in higher education. Anita has edited several Norwegian books on health professional education and supervision in higher education. She is the founder and former leader of the national network for supervision in clinical placements in Norway.

Notes

1. Values/ethics; roles/responsibility; interprofessional communication; and teams/teamwork.

Appendix Appendix A

Observation Protocol

Table

WHEN	Date/Time
WHAT	What type of activity is going on? What do participants do? What do the participants say?
HOW	How is the activity performed? What do participants do? Body language/gestures/mood How do they sit/position themselves? How do they dress?
WHO	Who/which people are involved? Who talks to whom?
WHERE	Where does the activity take place? What does the physical environment look like? DRAW THE ROOM/PEOPLE’S LOCATION/IMPORTANT ITEMS
QUESTION	Current follow-up questions – to whom
PARTICIPANT REACTIVITY	Inquiries to the researcher from participants Could some of the behavior be due to the researcher’s presence? Could some of the behavior be due to the research question and focus of the research project?

• What are your first impressions of the situation?

• What do you experience/react to/are significant or not expected in the situation? How do people in the group react to this?

• Is there anything the people in the group react to otherwise?

TIPS for jottings;

1. Write down details of critical components (observed situations, interactions)

2. Write down sensory details (about the room, nonverbal expressions, colors, and shapes)

3. Write down what is being said, not your interpretation of it. Write down individual words that can help you remember the dialogue.

4. Write down emotional expressions.

5. Write down general impressions and feelings you get.

Appendix B

Interview guide for supervisors of interprofessional student groups

Interviews with supervisors were based on 1) the researcher’s observation of supervisors in interaction with the students/patient and 2) aspects that the researcher had not observed.

Table

Theme	Featured Questions
Introduction	Welcome Information about what the interview entails The purpose of the interview is to elaborate on what I have observed during the interprofessional placement and to shed light on it from the supervisor’s perspective. Be honest about what you mean; everything said today is treated with confidentiality and will not be traced back to you. The interview is recorded on an audio recorder, and I may take some notes along the way to keep in mind things that I will follow up on/ask you questions about later in the interview. Duration approx. 40–60 minutes Please turn off your mobile phone or other things that may cause disturbances during the interview. Can you confirm that you consented to participate in the interview? Inform about the possibility of withdrawing consent or requesting access to what concerns the participant in the data material
Supervisor’s background/context
	Tell us about your practice as a health practitioner and supervisor for students
	How long is your professional practice?
	How long have you supervised students in clinical placements?
	How long have you been supervising interprofessional groups?
	Can you think back to when you first heard about interprofessional collaborative learning taking place in clinical placements, what did you think about that?
Key topic: About the supervisor’s understanding of interprofessional placements with patients
	What is the purpose of interprofessional collaborative learning in clinical placements?
	How is it organized here with you?
	Who is involved?
	What do you want to achieve?
Key topic: About the supervisor’s preparations for the interprofessional placement
	What preparations do you make before the placement period?
	What role does the supervisor have in this?
	How does the selection of relevant patients take place?
	What is the selection based on?
	How are patients prepared?
	What is your role in relation with the patient?
Key topic: Supervision of the interprofessional students during the placement and the patient’s role
	Tell us about how you follow up the group during the day/week?
	What did you do as a supervisor?
	Who does what?
	What happened when the students met the patient?
	Alternatively: What were the reasons why the students did not meet the patient?
	What do you think a patient meeting could have contributed with?
Key topic: On reflections on interprofessional learning and the patient’s role
	What happened when the students met for the reflection meeting?
	What did you do as a supervisor?
	What did you emphasize in the supervision?
	What guides the emphasized topics in the supervision sessions?
	What happens to the students’ view/understanding of (own role in relations to the patient/patient’s role) through the reflection meeting?
Ending
	Summary of the interview
	What has it been like to have a researcher with you this day/week?
	How has the interview been?
	Is there anything that you think should have been done differently?
	What do you think is the most important thing we’ve talked about in the interview?
	Thanks for participating!

Situations from the past week which may be relevant to elaborate on: