Clinical supervisors’ experience of giving feedback to students during clinical integrated learning

ABSTRACT

Background: For students within health-care education, clinical integrated learning has an important role in combining theory and practice. Constructive feedback is a cornerstone of effective clinical teaching, even though it can be a challenging task for both students and supervisors. There are limited studies on clinical physiotherapists’ experience of giving feedback to students.

Purpose: To explore clinical physiotherapy supervisors’ experience of giving feedback to students during clinical integrated learning.

Method: Twelve physiotherapists were interviewed in focus groups about their experiences of giving feedback to students. The interviews were analyzed using qualitative content analysis. Results: One latent, overarching theme was identified, which was continuous development and support within the social network at the workplace facilitates the work of giving feedback to students and three manifest main themes: (1) constructive dialog; (2) professionalism; and (3) enabling strategies.

Conclusion: The current study focuses on supervisors’ experiences of giving feedback to students in a clinical setting. The findings showed that giving feedback to students was a part of continuous development, facilitated by the social network at the workplace, and that the supervisors aimed to be professional while handling emotions in social interactions between supervisors and students.

KEYWORDS:

• Feedback
• physiotherapy
• clinical integrated learning
• supervision
• medical education

Introduction

Clinical integrated learning in health-care education combines theory and practice and has an important role in developing students’ abilities in clinical reasoning (Higgs, Jones, Loftus, and Christensen, 2008). Feedback is widely accepted as an integral part of clinical teaching and learning processes (Hattie and Timperley, 2007; Hesketh and Laidlaw, 2002). Giving and receiving feedback can be challenging for both supervisors and students, and the literature shows increased reports of dissatisfaction (Adcroft, 2011), which is a concern with regard to quality development in health-care education. In the literature, a large number of studies reports on feedback and how to assess it. However, there is limited research that explores the physiotherapy supervisors' perspective on engaging in feedback conversations with students.

In effective clinical teaching, feedback can reinforce good practice as well as being corrective (Hesketh and Laidlaw, 2002). Sadler (1989), described feedback as a formative assessment, intended to improve performance and advance the learning process. It should be a two-way dialog with interaction between the supervisor and the student (Nicol and Macfarlane-Dick, 2006) in a safe environment to enable honest and constructive feedback (Fluit et al., 2013). There are reports of a gap between supervisors’ and students’ perceptions of feedback with supervisors reporting provision of feedback and students denying receiving it (Branch and Paranjape, 2002; Jensen et al., 2012; Sender Liberman et al., 2005). From the students’ perspective, perceived issues reported concern the technicalities of feedback, such as content, assessment, timing, and lack of clarity about requirements (Higgins, Hartley, and Skelton, 2001; Huxham, 2007).

Despite consensus on the importance of feedback, the increasing reports on students expressing dissatisfaction with feedback originate from many different causes (Boud and Molloy, 2013). Students perceive that they get insufficient feedback (De et al., 2004; Sender Liberman et al., 2005). From the supervisor’s perspective, it can be hard to get the balance right, Bing-You and Trowbridge (2009) described how a supervisors’ behavior in combination with the students' limited metacognitive skills affects the feedback situation. Furthermore, feedback also needs to be limited to the amount of information the student can use rather than what the supervisor might want to give (Quilligan, 2007).

A review from 2017, about feedback in medical education, found that more than 80% of the studies concerned medical students and less than 1% included physiotherapist students (Bing-You et al., 2017). Jarski, Kulig, and Olson (1990) reported that physiotherapy students and clinical teachers perceived that the most effective clinical teaching method was to provide information through feedback. Bearman, Molloy, Ajjawi, and Keating (2013) showed that clinical physiotherapy supervisors felt responsible for the success of their students in clinical education, and to help students who were underperforming, they gave more feedback as an effective educational tool.

An evaluation, using the Maastricht Clinical Teaching Questionnaire (Stalmeijer et al., 2010), among clinical physiotherapy supervisors at Karolinska University Hospital, Sweden, revealed that the supervisors felt it was difficult to provide feedback to students. As a result, the clinical teachers at the physiotherapy department developed and initiated several tools for the supervisors, with ideas on how to work with feedback. Examples of introduced optional tools: a workshop created by experienced supervisors where new colleagues could share experiences with each other, supervisor pairs to encourage peer-teaching, production of a short film including five pieces of advice about providing feedback (Halvarsson and Sellberg, 2016) and reflection assignments about feedback. The reflection assignments were based on Significant Event Analysis (Pringle et al., 1995) and PEER-learning (Cohen, Boud, and Sampson, 2001).

In the present study, feedback was considered the formative assessment intended to improve and accelerate learning (Sadler, 1989) and defined as a constructive dialogue between a supervisor and a student, about the gap between the current level and the desirable level and how to alter the gap to achieve the learning outcomes. The definition is inspired by a definition by Ramaprasad (1983) and strives for a constructive dialogue (Pintrich and Zusho, 2002) aiming for feedback to shift from a didactic delivery of information toward a conversational model as suggested by (Molloy, 2009).

A clinical supervisor was defined as a physiotherapist assigned to facilitate students’ learning during clinical integrated learning. The definition is inspired by Smedley (2008) who described the supervisor’s role as a facilitator of the development of knowledge, clinical skills, and professional attributes. With the knowledge of the importance of feedback in effective clinical teaching, it is crucial to also gain a deeper understanding of the physiotherapy supervisor's perspective. The aim of the present study was to explore clinical physiotherapy supervisors’ experience of giving feedback to students during clinical integrated learning.

Methods

Design

To describe and explore clinical supervisors' experiences, a qualitative approach was considered suitable as human experiences were being explored (Creswell and Poth, 2017). Such an approach provides valuable and enriching descriptions of complex phenomena and, as argued by Sofaer (1999), has much to contribute to health services. An interpretive approach was chosen to examining the phenomenon in its natural setting and with the interpretative paradigm that knowledge is viewed as relative and socially constructed (Creswell and Poth, 2017).

Setting and informants

The context of the present study was a university hospital where physiotherapy students from a medical university have clinical placements. As a bridge from the medical university to the university hospital, a teaching team, consisting of three clinical teachers, provided support to both supervisors and students. The three members of the teaching team are specialized physiotherapists and have different roles, two are clinical coordinators and one is a faculty member. All clinical supervisors of physiotherapy students in semester 3 during autumn 2016 were invited to participate. Participation was voluntary and the supervisors were informed that they could withdraw at any time.

The study was approved by the Regional Ethical Review Board in Stockholm (Dnr 2016/1425-31). All informants received written and verbal information about the study and gave their written informed consent to participate. Data were treated anonymously; each participant was deidentified and given a code in chronological order, by MS. The key was stored separately from the data.

Data collection

A semi-structured interview guide with open-ended questions was used during the interviews (Table 1). The informants were asked questions about their experiences of giving feedback to students. The interviewer started the discussion, moving from general to more specific questions on their experiences of giving feedback. The interviews were audiotaped. Focus group interviews involve bringing together people of similar backgrounds and experiences to participate in group interviews about major issues that affect them (Patton, 2002). The collection of data through focus group interviews was considered the right method according to the aim of the study because this method can elicit responses about sensitive topics and the dynamics within the group can provide data that are not generated by other methods (Wellings, Branigan, and Mitchell, 2000). The interviews were audiotaped. The interviewer had no previous relationship to the informants but had the experience of conducting focus group interviews.

Table 1. Interview guide (translated from Swedish)

Interview guide
How would you describe giving feedback to your students?
Share a situation when it was easy to give feedback.
Share a situation when it was difficult to give feedback.
How do you know if the feedback you gave was good or bad for the student?

Data analysis

An inductive qualitative content analysis was employed to explore the collected data (Graneheim and Lundman, 2004; Krippendorff, 2018). The interviews were transcribed verbatim by the first author and thereafter distributed to the other three authors. The transcripts were then systematically analyzed in several steps using qualitative content analysis (Graneheim and Lundman, 2004) with the informants’ experience of giving feedback to students as the unit of analysis, see Table 2 for an overview of the analysis process from meaning units to subthemes. The analysis sought to identify both manifest themes and underlying latent meanings. These themes are described by Watzlawick, Bavelas, and Jackson (2011), manifest content is expressed as what is said and the latent content the underlying meaning. With the aim of the study in mind, the first author read the transcripts repeatedly to get a sense of the whole and reduced the text to meaning units, the challenging meaning units were discussed within the research group until consensus prevailed. The meaning units were condensed, labeled with codes, and grouped into subthemes to ensure the themes were mutually exclusive. The analysis process involved back-and-forth movements from the whole to parts of the text (Graneheim and Lundman, 2004). To ensure conformability throughout the analysis, several debriefing meetings took place with all authors to discuss the coding and themes until consensus was reached. Group discussions led to the development and refinement of the overarching latent theme. An overview of the steps in the analysis process is provided in Table 3. The analysis was conducted in Swedish and the quotes were translated into English by the first author and critically reviewed and verified by the research group.

Table 2. Example of the stages of the analysis process from meaning units to subthemes

Meaning unit	Codes	Subtheme
It is easier to give when you get a response. When I asked about the situation, I got something back	Response	Promoting factors
It is hard to give feedback to someone who does not say anything	No response; no dialog	Aggravating factors
I notice if the feedback was good or bad when I see a change over time. It is like a receipt if he changes his way of doing it	Change over time; confirmation	Reaction to feedback
Experience-wise, the years in the clinic weigh heavily	Clinical experience weigh heavily	Credibility
It is fun to be present when someone grows as a human being. To be a part of the process. It is nice. It is gratifying	Part of development; gratifying	Emotional impact
If you have a lot to do, you cover if a colleague is ill and it affects me and how much time I have for the student, even though I know that I should prioritize the student	Own mood	Approach
I know how to give feedback but lack words. The film helped me. For example, I can ask the student when she wants feedback. I got structure	Educational tool; concrete tips; structure	Educational tools
We worked in a supervisor pair. It was my first student, it was my colleague who took perhaps more responsibility, and introduced the structure and showed what we should go through and the compulsory parts, and I learned how to do it	Collaboration in supervisor pair; new colleague learned	Competence development
Often it is good to just put words to the problem and talk about it with someone who sees it from another perspective	Put words to the problem; another perspective	Support

Table 3. Overview of the steps in the analysis process

Steps in the analysis	Performed by
Transcription	MS
Review of transcription	MS, AH
Reading of transcriptions	MS, KSR, MNB, AH
Condensation to meaning units	MS
Group discussions to achieve consensus	MS, KSR, MNB, AH
Coding	MS
Initial grouping into subthemes	MS
Group discussion to achieve consensus on subthemes	MS, KSR, MNB, AH
Group discussion to decide on themes and overarching theme	MS, KSR, MNB, AH

All authors were health professionals with backgrounds in physiotherapy and expertise as clinical teachers with extensive experience in pedagogy and as health professionals. Three authors had worked in the field of clinical education for many years; 20 years (MS), 15 years (MNB), 10 years (AH), and three of them (MNB, KSR, AH) had extensive experience of qualitative research, with emphasis on qualitative content analysis. According to Elo and Kyngäs (2008), the researcher’s position and reflexivity in qualitative research are of paramount importance at all stages of the research process. Therefore, the researchers’ professional background as educators and physiotherapists with experience ranging from basic to advanced education and clinical integrated learning could affect the data collection and analysis processes. The researchers maintained constant awareness of how preconceived notions could affect the study by having reflective discussions which led to a deeper awareness.

Trustworthiness

To ensure the trustworthiness of the results and limit threats to validity, this study used the criteria for trustworthiness described by Lincoln and Guba (1985) which are credibility; dependability; transferability; and confirmability.

With regard to credibility, knowing that the teaching team (MS and AH) conducted the study could be a source of bias and influence the supervisors from speaking freely, potentially affecting the analysis since the informants were colleagues and might not be comfortable about disclosing negative experiences of working with the teaching team. To minimize the bias and create a distance from the study, the interviews were conducted by a person who had never met the informants before but had good insight and knowledge about the aim of the study and previous experience of focus group interviews. The interviewer was familiar with the language of the research setting and could, therefore, address certain topics or follow-up questions during the interviews. This might have influenced both the amount and quality of the data in a positive, enriching way. The study was conducted immediately after a 5-week period with students in the clinic when the supervisors had the topic of feedback fresh in their mind. The interviews took place in a conference room at the hospital where the informants were not disturbed by clinical duties. The interview setting was familiar and safe for the informants.

When analyzing the data, the authors perceived the interviews as rich, containing both positive and negative aspects because both benefits and fears were discussed, which indicates that the supervisors felt safe enough to express their true opinions. Credibility describes the aim of the research and how the data and analysis process conforms with the aim. This was met through open-ended questioning, prolonged engagement with the data, and by providing a detailed description of the methods. In order to make the study findings trustworthy and believable to others, investigator triangulation was used, which can be seen as enhancing the credibility of the study (Patton, 2002). Researcher KSR, who had never met the supervisors, was invited to participate in the analysis and added to the objectivity of the analysis and contributed with an outsider’s view of the data. AH, MNB, and KSR have extensive experience in qualitative research, and with qualitative content analysis.

Dependability refers to the stability of data over time and how the researcher’s decisions in the analysis process could change and influence the outcome (Elo and Kyngäs, 2008). This was met by reading the transcripts several times, with the coding checked and discussed by all authors until an agreement was reached. A semi-structured interview guide was used to achieve stability in the data collection. Since two groups were interviewed, it was important to include the same questions in both interviews.

Transferability was met by presenting detailed and in-depth descriptive data and by quoting participants in the text. The present study gives a rich description of the informants and the clinical setting, which enables the reader to evaluate transferability to similar settings and can be of relevance for related professions and health-care facilities where clinical integrated learning occurs. Confirmability was met by providing rich quotes from participants that depict the support for each theme.

Results

Twelve out of thirteen clinical supervisors accepted participation. Their mean age was 36 years (range, 25–62 years). Four were supervisors for the first time, four had supervised five students or fewer, four had more than 10 years of experience of supervision, and the number of years as a clinical supervisor ranged between 0 and 36 years. Five had no theoretical pedagogic education, three had undertaken a web-based theoretical course in supervision, and four had pedagogic higher education credits. Two supervisors were specialized physiotherapists. The two focus groups consisted of six participants and lasted for about 65 min each.

The inductive qualitative content analysis resulted in an overarching theme that was underpinned by three main- and nine sub-themes: continuous development and support within the social network at the workplace facilitates the work of giving feedback to students (Figure 1).

Figure 1. The overarching theme, main themes, and subthemes identified as a result of the analysis.

The overarching theme refers to the scale of a challenging task; a student is shaped by feedback from more than one supervisor. It is considered a strength that the supervisors can collaborate within a community where they can get help and advice, although this does not mean that it is impossible for one supervisor to handle one student. Within the network, the students benefited from the experience of a whole community rather than one supervisor alone. The social network consisted of other colleagues, other supervising colleagues, the colleague within the supervisor pair, and the teaching team. By collaborating, the supervisors got inspiration and new ideas on how to develop the process of providing feedback. When they found themselves in difficult situations, they used their network to get someone else’s view, which also meant they did not feel isolated. The analysis showed that both inexperienced and experienced supervisors benefited from and actively chose to collaborate within the network. The supervisors expressed that the teaching team gave them increased status and highlighted the importance of having clinical supervisors.

Theme 1: constructive dialog

This main theme is described with its three subthemes: (1) promoting factors; (2) aggravating factors; and (3) reaction to feedback. The supervisors strived to create a constructive dialog with the students. This included promoting and aggravating factors and the students’ reaction to the feedback given. The supervisors expressed that they expected a response from the students; they wanted something back that they could use for further development of the supervisors' feedback skills. The analysis showed the need for constructive dialog, in the development of feedback skills as described in the following quote:

Anyone who wants to reflect and talk about what he experienced opens up the way for us. It is about daring to talk and daring to tell your thoughts. Maybe that’s what we need as supervisors initially. We would love to know what they think and how they experience things. Informant 6

Active, reflective students with self-awareness were favored to give feedback. In order to create the best possible prerequisite for the student to reflect, the supervisors wanted to create a confidential and safe environment. This was done by practical arrangements such as regularly set aside time for reflection after feedback was given. A student who reflected after receiving feedback in a way confirmed for the supervisor that they had understood the feedback and described it as having received a receipt. Promoting factors were explained as follows:

I had a student who was easy to talk with, who herself reflected a lot and took the initiative with feedback. She told me what she thought could be better and what was already good; it became easier to respond and say what I felt/ … /It made it easier for me, too, that she wanted to share. Informant 1

The subtheme of aggravating factors concerns the factors that challenge a feedback situation. The supervisors highlighted silent and nervous students or students with an unprofessional attitude as difficult to have a constructive dialog with. At the same time, difficult moments in the feedback situation could be profitable in the long term. A challenging situation could be waiting for a quiet student to begin to reflect on the performance. Giving feedback on professional behavior to a student who talked over or interrupted others may have been perceived by the student as an attack, but was important feedback to assist students to achieve the learning goals in collaboration with others. Another challenging situation was, while giving constructive feedback, at the same time deciding how much feedback the student could handle. This leads to supervisors needing to prioritize feedback messages. Also, no response to feedback or negative body language was considered difficult to deal with.

I tried to talk with my student but she remained silent … without a response, it is hard to have a dialog … so I told her what I had seen but I would have preferred a dialog to get access to her opinions as well. Informant 8

Furthermore, the non-verbal reaction was an important part when giving feedback. The supervisors observed how students responded to feedback, both in single instances and over time. Changes in behavior and ability to self-reflect were confirmation for the supervisor that the student had embraced the feedback. To get access to non-verbal communication, the supervisors had to be mentally alert at every moment, and they expressed the importance of assessing the atmosphere in the room and reading the student’s body language. Non-verbal communication, a sense of mood assisted in interpreting whether the student was likely to be able to make use of the feedback:

I observe the body language of the student. They [students]can react in different ways; everything from looking very interested and taking it in to … you sometimes see that it is too much. The student has shut down. It is clear, I think. Informant 4

Theme 2: professionalism

This main theme is composed of three subthemes: (1) credibility; (2) emotional impact; and (3) approach. The theme shows how careful the supervisors were to carry out their job as well as possible and to have a professional approach when giving feedback. They also pointed out factors influencing their credibility; nevertheless, they always took full responsibility for their assignment. Providing feedback could be associated with strong feelings, but they did not hesitate to carry out their obligation as clinical educators. One of the informants expressed:

We realized that he [our student] knew much more than we did as students … We had to reflect deeply on how we could help him develop … it was difficult. It does not have anything to do with my self-esteem; he must achieve personal development. Informant 6

The supervisors discussed their credibility toward the student in terms of the number of years of experience in the profession and academic level. They deemed that with more years in the profession, given the power differential between the supervisor and student it was less likely that a student would question a supervisor in a feedback situation. Also, their credibility toward students was strengthened by the fact that there was a teaching team responsible for the educational assignment.

/ … /the fact that we have a teaching team shows it is important to be a supervisor, it is an important activity, and it gives an extra boost … It is something good [for the field] we do when we have the students here. Informant 4

Providing feedback could be associated with an emotional impact for the supervisors. When giving feedback was successful, they experienced positive feelings such as pride, affirmation, creativity, and satisfaction. The supervisors felt positively involved in the progression and saw the potential of the collaboration with the student. In contrast, the supervisors perceived feelings of failure, frustration, dissatisfaction, effort, and stress when they had to give negative feedback. Giving feedback to weak students or defensive students led the supervisors to feel they had failed in their educational assignment which brought a feeling of helplessness due to the lack of progression. An example of this feeling was voiced with the following quote:

You feel most frustrated, I think. What should I do to achieve it [progression] and for the student to embrace it [being given feedback] to achieve learning outcomes? Informant 7

The supervisors had a structured approach to giving feedback, which they regarded as a core professional task. This included being well prepared for feedback situations and they were respectful of the students’ right to receive constructive feedback, including students for whom feedback situations were more challenging. The supervisors sought to protect the students from the stressful work and personal problems that the clinical supervisors may have experienced at the time of clinical placement. They sometimes collaborated with a colleague in joint teaching by taking both their own student and one more, providing a good opportunity to give the other supervisor time for clinical duties. They did not consider that praise from a student was a confirmation that they were good supervisors. It was more important that the student made progression toward the learning outcomes than to be praised by the student for being a good supervisor. If the relationship between supervisor and student was challenging or developing slowly, it could help to patiently work on understanding the student:

I had a student and we had not been able to get to know each other. After about 3 weeks, it resolved. It is about understanding each other. How we can improve the relationship. I had to understand what he meant and he had to understand what I meant. After that, it went well. You have to get to know each other and it can take some time. It may not work right away. Informant 5

Theme 3: enabling strategies

This theme is composed of three subthemes: (1) educational tools; (2) competence development; and (3) support. The theme describes the strategies and the educational tools that the supervisors used in the feedback situation and how they acted to develop competence in giving feedback and support in a difficult feedback situation. The enabling strategies are illustrated with the following quote:

I think it’s a great help to reflect with a colleague, it’s very important. Especially when you end up in a situation where you feel you are not doing so well or, you try but do not succeed. Informant 7

The supervisors used several educational tools provided by the teaching team to develop their feedback skills. They considered the tools fun and easy to use. The tools provided more structure to guide the feedback process. The film about feedback provided examples on how the supervisors could express themselves in dialog with the student and prompted discussion about feedback among colleagues:

I have seen many [feedback] documents … over the years. But this film, I can watch it several times. It is so short, concise, fun and well made. It highlighted this [feedback] … and among colleagues we talked with each other about it [feedback]. Informant 2

Competence development dealt with how supervisors made sure they acquired the knowledge and skills to create effective feedback situations. The most common way to gain practical knowledge was to talk to a colleague. For knowledge about education methods, clinical supervisors consulted the teaching team. Some of the supervisors attended a pedagogic course at the university; it was considered good and they expressed that it dealt with the same subjects as the ones the teaching team raised in the clinical environment. By working with colleagues, supervisors shared strengths and weaknesses. Some supervisors expressed a fear that collaboration with a colleague would have an adverse effect on their work. The following quote is one example of how one supervisor learned from a more experienced colleague:

It was my first student; my experienced colleague took more responsibility and taught me how she did it [provided feedback]. Informant 2

In difficult feedback situations, characterized by a non-reflective student, lack of progression, dissatisfied students, it was important for the supervisors to have support and someone to share problems with, not try to solve things alone. In these situations, the supervisors turned to a colleague or the teaching team for help. They also described that difficult feedback situations brought a fear of losing their own faith in their ability as supervisors. Talking to a colleague was considered a great support and provided new insight into new approaches, a feeling of participation in a community of supervisors, and not being left alone with the responsibility of supervision. The teaching team helped the supervisors with an individualized and structured plan and by supporting both the supervisor and the student. The following is an example of the support received:

I had a weak student and at that time, the teaching team was very important. We had weekly meetings during that period and discussed what needed to be done better to achieve the goals … it was very good to have them [the teaching team], we shared the responsibility. Informant 8

Discussion

The aim of the present study was to explore the experiences of clinical physiotherapy supervisors giving feedback to students during clinical integrated learning. The results from the analysis show that it is a task of continuous development where the supervisors aim to be professional in their clinical supervision practice while managing their emotions in interactions with students. The results reinforce that the role of supervisors’ giving feedback to students is complex and multifactorial. The quality of the relationship between the supervisor and the student is considered the most important factor to achieve effective supervision (Kilminster and Jolly, 2000), and the clinical supervisor plays a fundamental role in enhancing student learning (DeClute and Ladyshewsky, 1993; Gignac-Caille and Oermann, 2001). In the present study, this was reflected in how the supervisors took on the feedback assignment with a strictly professional approach, and with an uttermost commitment that their feedback would lead to reflection and continued learning for the student.

In the study, the supervisors described how they aimed to have a constructive dialog with the student and understand what kind of support was needed to fulfill intended learning goals and objectives. This finding is in accordance with Blair and McGinty (2013) who concluded that dialog is important for confirmation that feedback is understood as intended. In addition to dialog, they also observed how the student’s acted on the feedback, both directly and over time. Careful assessment of the amount of feedback has been described earlier in the literature; if there is a large amount of feedback, it may overwhelm students and leave them unable to take in more than a fraction of the feedback (Brockbank and McGill, 1998). The effectiveness of feedback is also contingent on the engagement of the student (Boud and Molloy, 2013), which confirms the importance of assessing the students’ reactions. Self-knowledge and self-esteem are reported to affect how the student receives feedback (Öjestad, 2010). Furthermore, Adcroft (2011) argued that supervisors and students may have their own thoughts on feedback, which may create dissonance when the feedback results in different interpretations by supervisors and students.

It has been described that supervisor working with a failing student distanced themselves from their actions by using the pronouns “we” instead of “I” and that the supervisors were concerned about norms and the views of other colleagues about the individual student (Adcroft, 2011; Monrouxe, Rees, Lewis, and Cleland, 2011). The present study confirms that giving negative feedback can be unpleasant for the supervisors if the students do not react as expected. An interesting result in the present study is that the supervisors did not hesitate to give more challenging feedback or postpone it as described by Vorvick, Avnon, Emmett, and Robins (2008). In the present study, it was important for the supervisors to act professionally, and it was also socially acceptable to admit difficulties in the feedback situation to colleagues. The structure the teaching team created for the educational assignment contributed to create an atmosphere where it was socially acceptable to discuss one’s own and students’ weaknesses. The supervisors were emotionally affected by the feedback situation. Giving positive feedback brought energy and job satisfaction while difficult feedback situations led to negative emotions. Similar reactions were described in a test situation among teachers who experienced negative emotions when they encountered challenges from the students (Stough and Emmer, 1998). The commonly reported strategy in these situations, for supervisors in the present study, was to seek help from a colleague or the teaching team.

Gunnarsson (2013) has described a functional and a dysfunctional feedback culture, where the good culture includes openness, whereby the supervisor is interested in other people’s views, even if they are new and different. Challenges in such a culture are dealt with in a similar way as in the present study, in the way that the supervisors reported that they found a collegial support at the workplace. Research has found that supervisors know little about the factors that influence how the student is affected by the feedback; these factors include previous experiences, self-knowledge, and self-esteem (Öjestad, 2010). The individuals’ mood and sense of priority may influence how a given task will be resolved; individuals in a positive mood prefer weakness-focused feedback when it is useful for the learning purposes to a higher degree than individuals in a neutral mood (Trope, Ferguson, and Raghunathan, 2001). The supervisors in the present study described that they had to be mentally present to assess how much feedback the student could handle.

Previous studies have shown that supervisors require ongoing feedback and support from clinical coordinators and clinical faculty members in terms of frequent visits and support in the evaluation process (McCarty and Higgins, 2003). This is in accordance with the results from the present study where the teaching team represents clinical coordinators and faculty members. The supervisors described that geographic proximity to support was crucial and both competence development and support took place within the workplace. The teaching team contributed to a feeling of shared responsibility. Luhanga, Yonge, and Myrick (2008) reported that nursing supervisors were more likely to make crucial decisions about student performance when faculty supported them. The supervisors in the present study described that they were comfortable about asking for help in vulnerable situations and that they got support from both colleagues and the teaching team.

Strengths and limitations

The composition of the research group in the present study, researchers with different preunderstanding about clinical integrated learning and knowledge about the analysis method, is considered as a strength. One researcher who had no connection to the supervisors or the context opened up for creative discussions during the whole analysis process.

Two of the authors were colleagues to the supervisors and members of the teaching team (MS and AH). With regard to credibility, knowing that the teaching team conducted the study, it could be a source of bias and may have influenced the supervisors while getting introduced to the different educational tools and could have prevented them for speaking freely and disclose negative experiences or aspects of the study. However, the rich data from the interviews, including both negative and positive aspects, could be interpreted as the opposite. One explanation for this could be the use of an outside person who conducted the interviews. Which might have influenced the amount and quality of the data in a positive, enriching way.

The data in the present study are based on two focus group interviews. In qualitative research, the sample size may be considered less important than variation in the data generated (Graneheim and Lundman, 2004). We consider the sample size (n = 12) representative since all supervisors were asked to participate and all but one accepted. The rich description of the informants and the clinical setting enables the reader to evaluate transferability to similar settings.

Conclusion

The current study focuses on supervisors’ experience of giving feedback to students during clinical integrated learning. The findings conveyed that giving feedback to students is a task involving continuous development where the supervisors aimed at being professional while handling emotions in social interactions between supervisors and students. The supervisors found support within the social network at the workplace, which is considered a favorable working environment.

Disclosure of interest

The author reports no conflict of interest.

Acknowledgments

Special thanks to the supervisors who devoted their time to participate in the study and to Agnes Elmberger who conducted the interviews. We are also grateful to Klara Bolander Laksov and Riitta Möller for valuable discussions and constructive feedback on medical pedagogic education.