RESEARCH

 

Factors influencing clinical supervision of undergraduate occupational therapy students during practice learning in the Global South: A rapid review

 

 

A Ebrahim^I; P R Makwambeni^II; S Damonse^III; J Marais^III; K Perumal^III; S Philpott^III; B Rooseboom^III; K Shefer^III

^IPhD (Disability Studies), MEd, BSocSci, BSc (Occupational Therapy); Division of Occupational Therapy, Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, South Africa
^IIPhD (Information Systems), MA (Archives and Records Management); BA Hons (Library and Information Science); Bongani Mayosi Health Sciences Library, University of Cape Town Libraries, South Africa
^IIIUndergraduate occupational therapy student; Division of Occupational Therapy, Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND. Clinical practice learning is an important aspect of educating undergraduate occupational therapy (OT) students to understand the profession and for professional identity. Practice learning could be hampered by several factors including the lack of proficient clinical supervisors, coupled with a burgeoning number of students. To ensure the success of the programme, the expectations of lecturers and supervisors should be compatible.
OBJECTIVE. To investigate the factors influencing clinical supervision of undergraduate OT students during practice learning in the Global South.
METHODS. A rapid review of the literature was conducted between 2017 and 2022 with searches in EBSCOhost and PubMed databases. Mendeley Reference Manager was used as a tool for database storage, and the literature found was screened and documented according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and guidelines. A hierarchy of evidence was formed using Tomlin and Borgetto's (2011) research pyramid. Articles within the three most trustworthy and relevant levels of the qualitative hierarchy were appraised using the clinical appraisal skills programme (CASP) tool.
RESULTS. Five main themes emerged from a thematic analysis of 20 records: quality assurance; roles and relationships; hegemonies in and out of context; context of clinical practice; and teaching how.
CONCLUSION. The key aspects influencing clinical supervision in undergraduate OT programmes are interconnected. The findings emphasise the importance of having a protocol, sequence of preparation and procedure, and training of personnel in informing quality of supervision. Quality individualised support for learners is best achieved when there is structure and proficient supervision.

Keywords: clinical supervision, occupational therapy training of undergraduate students, Global South

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Occupational therapy (OT) is a health profession that promotes health and wellbeing through participation in occupation. The primary objective of OT is to enable people to engage in meaningful activities of everyday life.^[1] An occupational therapist has completed 4 - 6 years of a theory-based OT qualification, depending on the countries and institution offering.^[2] A clinical practice learning component is often added to most OT curricula at the undergraduate level to bridge the gap between theory (acquired through didactic lectures) and practice (in clinical settings). Experiential learning in the form of clinical practice promotes the development of a professional identity and deepens the student's understanding of the profession.^[3]

During clinical practice, students work under the guidance of a clinical supervisor. Clinical supervision for OT students is a process of senior and more experienced occupational therapists guiding students in their development as competent professionals.^[4] The clinical supervisor offers support in stimulating the development of clinical skills that are required from the student within practice settings. Clinical supervision provides an opportunity for the translation of theoretical learning from the classroom into the practice setting.^[4] Additionally, ensuring patient safety and high-quality patient care throughout student therapeutic interventions is essential.^[5] Included in the supervisor role are the responsibilities of assessing and monitoring the students' performance to determine their readiness and ability to integrate therapeutic techniques.^[6]

Supervisors also provide socio-emotional support. Socio-emotional support refers to a personal approach to teaching where the supervisor goes beyond inculcating professional knowledge and skills - also providing emotional and social support to the individual student. The supervisor is constantly aware of the students' needs and adopts a supervisory role that is effective for the students' learning and their personal growth as individuals.^[7] This type of support shapes a supportive environment for learning because it helps students to feel valued, respected and emotionally secure, which can positively impact their learning experiences and overall wellbeing.^[7[

 

Problem statement

OT concepts, theories, models and learning resources have historically been developed in the context of the Global North and have been based on the pertinent contextual factors that are experienced in the North and not the South.^[8] Typically, countries in the Global North have more political influence, developed economies and access to infrastructure and growth. Conversely, their counterparts in the Global South face a number of challenges such as poverty, political instability, limited access to education and healthcare and under-developed infrastructure. The terms Global North and Global South are not simply 'labels' denoting geographical divides, but relate to inequalities in wealth, economic growth, development and political power and influence of different nations. Examples of countries in the Global South include those in Africa, Latin Ameria, the Caribbean and parts of Asia.

Countries in the Global South cannot be perceived as being homogenous, as there are distinct cultural differences and inequalities in access to education, learning infrastructure and resources. This scoping review of the literature explores the factors that impact on clinical supervision of undergraduate OT learners in the Global South. It engages with factors that could hinder the successful supervision of OT students in these countries. The literature shows that OT theory and philosophy largely emanate from the Global North, with a dominant influence of western cultural values and liberal democracies and seldom non-western cultures. These liberal democracies are mostly evident in Western Europe and North America.^[9]

The complexities, subtleties and effects of non-western cultures and their influence on professional practice are given relatively little consideration.^[9] Cultural dissonance and philosophical contradictions occur in applying these western understandings of OT practice in non-western contexts. A study by Al Busaidy and Borthwick^[9] highlights the impact of cultural dissonance when western theories and practice were applied in the Middle Eastern Sultanate of Oman. The study showed that therapists found the need to adapt their practice to acknowledge the philosophical contradictions and to adopt pragmatic problem-solving strategies.^[9]

A number of factors could impede the successful execution of clinical practice learning for undergraduate students in the Global South context, such as the lack of resources in clinical practice sites.^[10,11] Public hospitals in the Global South are characterised by a shortage of healthcare professionals, including occupational therapists.^[5] There is a deficit of trained clinical supervisors for OT, as well as other allied health professionals, and the facilities are under-resourced.^[5] Studies have shown that clinical supervisors must juggle their own roles of responsibility and teaching of students,^[12] as there are often large cohorts of students and there is a shortage of fieldwork sites.^[13,14]

Often there is no synergy between what is expected by university lecturers and by clinical supervisors, thus creating a dissonance between theory and practice.^[13] Some studies show that there is tension between the academic expectations and the availability of the clinician to model skills that students are expected to master in the clinical environment.^[13] Allied health professionals in remote or rural settings have limited access to regular supported and organisationally mandated clinical supervision.^[15] Clinical supervision is important in the training and professional development of OT students.^[4] This rapid review aims to identify a comprehensive range of factors that influence clinical supervision in countries in the Global South. It also seeks to answer research questions.

 

Research questions

What factors influence the clinical supervision of undergraduate OT students during clinical practice learning in the Global South? What is the supervisor's role? What factors hinder successful clinical supervision of OT students in the Global South?

 

Methodology

A rapid review study design as postulated by Khangura et al.^[16] was used to address our research question. This design provides a streamlined approach to synthesise evidence, following the methods of a systematic review on a topic in a resource-efficient and timeous manner.^[17] As espoused in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), the method was based on the following steps: (i) a systematic search of the literature; (ii) screening; (iii) inclusion of appropriate studies; (iv) execution of a narrative synthesis from the chosen studies; and (v) production of an article.

Search strategy

Medical Subject Headings (MeSH) terms were generated on PubMed, from which a list of Boolean phrases was then created to also do the searches in EBSCO. The key concepts and relevant MeSH terms used to conduct the searches were based on the key terms: 'clinical supervision', 'occupational therapy' and 'undergraduate students'. We incorporated the Global South in our search by using filters for low- and middle-income countries documented by the World Bank country and lending groups. The full search strategy is documented in Supplementary files 1 - 4 (https://doi.org/10.25375/uct.23623575.v2).

The searches conducted on both EBSCOhost and PubMed were limited to the English-language literature published between 2017 and 2022 and scholarly (peer-reviewed journals) and grey literature, respectively. These search parameters ensured that the most relevant and credible research was selected for the review.^[17] From the search strategy described, the articles produced were evaluated using the inclusion and exclusion criteria (Supplementary files 1 - 4: https://doi.org/10.25375/uct.23623575.v2). The studies that we included were from the Global South, and covered clinical supervision of OT students or other allied health professionals. Articles that were excluded were not within the date bracket for inclusion and did not mention OT or any other allied health professionals. The PRISMA diagram (Fig. 1) shows how the review was conducted. Mendeley Reference Manager was used for organising and tracking articles.

 

 

Data collection and analysis occurred concurrently with the screening research process. Information extracted included the author(s), title, design, date of publication, country, target population and outcomes of each study. These raw data were organised using open coding, which included labelling phrases in the research as concepts and categories, using the research aims and objectives. Our objectives were to understand the factors that could impede or affect the clinical supervision of OT students during clinical practice learning by exploring the role of the clinical supervisor in the process and how the clinical practice environment located in the Global South affects the type of supervision given to students. A thematic analysis was then used to organise the information found in the included studies.^[18]

 

Results

The search was conducted on 11 March 2022. The initial search produced a total of 734 articles across the two databases. Duplicates were removed, leaving a total of 517 articles. After applying the date filters, we were left with 147 articles from EBSCOhost and 4 from PubMed; then, applying the scholarly journals filter and peer-reviewed articles there were 85 for EBSCOhost and 4 for PubMed. The EBSCOhost database allows one to filter under source type to scholarly articles that are peer reviewed. The 89 articles were shared among five researchers for title abstract screening. All peer-reviewed articles that discussed the clinical supervision of OT students within the specified time range of the past 5 years were included. Supplementary file 2 documents the exclusion criteria: studies that did not mention any of the allied health professionals, OT undergraduate students and practice learning. Thereafter, we had 24 articles for EBSCOhost and 0 for PubMed, which were screened through data extraction. Articles were placed on the Tomlin and Borgetto^[19] hierarchy of evidence. Two articles were excluded owing to being quantitative and mixed method studies, and could therefore not be placed on the Tomlin and Borgetto hierarchy of evidence. The 20 remaining articles were then discussed among the research members, were critically appraised and were deemed appropriate for this rapid review for their contributions of rich, relevant data that supported the answering of our research questions.

Risk of bias in article selection

To minimise the bias of this review, firstly, each article was screened for the level of evidence on the Tomlin and Borgetto^[19] research pyramid hierarchy. Two independent reviewers rated the articles according to the scale. From this process, the articles on all the levels of the research pyramid were included, except for articles falling on the lowest level of the pyramid (level 3). Secondly, the clinical appraisal skills programme (CASP) tool was used to appraise the trustworthiness and rigour within each study.^[20] The researchers acknowledged the researcher bias within the nature of using the CASP tool, as well as the process of conducting a rapid review.^[20]

Findings

Following thematic analysis of the 20 selected articles, five main themes emerged that explore and inform critical factors influencing clinical supervision of undergraduate OT students. Table 1 summarises the major themes and sub-themes.

Quality of the supervision

Several studies mentioned concerns from supervisors and students regarding the quality of supervision.^[13,14,21] However, none of the included studies assessed the level of competence of supervisors to ascertain their quality. In the study by Morrisby and Young,^[14] students reflected on work-integrated learning in care facilities. The views expressed by Patterson et al.^[10] were drawn from rehabilitation inpatients, clinicians (who were the supervisors), clinical education liaison managers and students completing practice placement. Ingwersen et al.^[12] explored the perceptions of students and clinical supervisors on fieldwork in OT. The study found that delivering quality clinical placements is complicated, and relied on universities, students, health networks and clinicians. Clinicians (clinical supervisors in Australia) play a crucial role in placements; they must be competent and prepared to support the training of undergraduate students.^[12] The quality of supervision is also compromised by clinical supervisors juggling between their usual work and supervision.^[12]

Findings showed that to ensure quality in supervision there is a need for preparation, the following of procedure and having protocols to manage expectations from the university, supervisors and training. Findings raised the importance of preparation before learners can be supervised. The supervisor should consider the impact of supervision on the current staff workload and also prepare the therapeutic medium that the students use, e.g. play as therapeutic medium, considering costs and ensuring patient safety.^[10] Supervisors need to gain an understanding of current curricular activities to best support student services. The students' skill level and previous exposure to field placement type also need to be considered.^[1410,12,14] While preparation was deemed important, literature however failed to give an outline of what the preparation of the practice learning environment would entail.^[12,1412]

Procedure

While no chronological process was reported in the literature, the key elements of the procedure of supervision appear to loosely follow a set of steps (Fig. 2).

Most of the included articles discussed the importance of a supervision protocol. A supervision protocol is a written document with procedures or guidelines to guide clinical supervisors on what is expected in the supervision process, defining roles and expectations from the university, as well as guiding decision-making.^[22-24] Three articles^[22-24] opined that there needs to be agreement on supervision among supervisors, students and the educational programme. This agreement should serve as a support structure for communication and responsibility among the three stakeholders.^[22-24] It was highlighted that supervisors and clinicians or staff require training, with few details about its nature and duration.^{[10,13,25,26]} Naidoo et al.^[13] were the only authors to mention a workshop for supervisors as a training space. Patterson et al.^[10] stressed the importance of supervisors having the skills for supervision, which could include the skills of collaborating to create learning experiences consistent with what is learnt in the classroom.^[21] Supervisors keeping up with current research can include understanding of contemporary and innovative models of supervision, improving the knowledge of frames of reference and theories, and improving understanding of evidence-based practice.^[21,22,26] Miyamoto et al.^[27] reported a need for supervisors to improve educational ability. The relationship between theory, research and practice is important. ^[21] One study found that supervisors either did not describe their use of this relationship well or did not know how to describe it.^[26] Quality of supervision was discussed against several concerns, such as differing expectations of supervisors, changes in healthcare systems, increasing student cohorts and shortages of fieldwork sites.

Roles and relationships

Of the selected articles describing roles, only four discussed student-specific roles.^{[11,12,27,28]} All 14 articles describing roles discussed details of roles of the supervisor (Table 2). One study provided role groupings of educative, supportive and administrative roles.^[25]

Hegemonies in and out of context

The clinical supervision relationship is embedded in context and contains its own power dynamics, as the supervisor is assumed to be an expert.^[25] In supervision, OT, physiotherapy and speech pathology students are reported to disengage when supervisors draw on this power difference.^[25]

Alternatively, if a student is acknowledged as a novice and there is a partnering, nurturing and facilitative process rather than a hierarchical one, there are more positive outcomes in engagement and learning for the student.^[25] The presence of students is even reported to stimulate critical reflexivity of the supervisors themselves,^[23,29] which suggests that supervisors acting as facilitators to the students in directing their learning process, relinquishing their position as the expert through remaining open to learning, and reflecting continuously, can dismantle the power imbalance that is often embedded in the supervision relationship.

Clinical supervision and its emergent practices are informed by the socio-historical, economic and political environment in which the student and supervisor live. These environmental influences, such as a predominately western culture, permeate clinical supervision relationships and produce dominant, frequently uncontested ways of doing and being.^[13] Naidoo et al.^[13] noted that while professional development focuses on western cultural values, particularly self-efficacy and communication, there is a dearth of research on how students from various racial and cultural backgrounds are expected to assimilate into these values. They also emphasised how crucial it is to recognise the distinctive experiences that students have as a result of their upbringing and education.^[13] For instance, it has been claimed that certain students' communication skills are badly impacted by English as a second language and not their mother tongue.^[11] Another study noted how a self-depreciating attitude that is culturally expected from younger people in relating with adults deemed as supervisors also impacts practice and supervision.^[27] In terms of student development, by engaging with OT practices, theories and expressions of professionalism from various cultural contexts, students deepen their understanding of OT.^[30]

Context of clinical practice

The concrete and observable dimensions of the immediate context, understood as the context of clinical practice, should ideally provide an opportunity for students to engage and participate in the reality of practice.^[31] It is critical that students are provided with placements that can support their learning needs and styles.^[32] Students highlighted that a welcoming environment was valuable in creating a positive learning experience.^[32]

While the necessity of clinical placements and supervision is widely acknowledged in integrating learning into practice, ensuring adequate skills development and decreasing stress that is often associated with the transition into clinical practice should be considered.^[28,32] OT training programmes are experiencing staff reductions and cost-saving measures,^[22] while facing pressure to facilitate students' development of essential skills, knowledge and attitudes.^[13] This situation influences the number of placements that can be offered, while the number of students and administrative demands continue to increase.^[31] Sourcing practice education opportunities becomes challenging, and when there are extreme staff shortages students are expected to form one core clinical team while still requiring supervision.^[22] The scarcity of placements raises concern regarding the impact on the quality of the supervision experience provided.^[21] There are benefits to having more than one supervisor overseeing each student, such as increased assessment objectivity and decreased time required of supervisors, but this requirement may not be possible within the constraints of the clinical context.^[11]

Teaching knowledge, skills, attitudes and behaviours of clinical supervisors

Findings showed that there is tension between the academic expectations and the availability of the clinician to model skills that students are expected to master in the clinical environment.^[13] Supervisors and students reported feeling pressure surrounding their workloads.^[30] In this system, clinical supervisors face significant pressure regarding time, and report that students reduce efficiency while increasing stress and workload, particularly when they are in their early years of study.^[12,33] However, students had either no effect or a positive effect on supervisor productivity.^[33]

It was also reported that supervisors need to use various effective skills development strategies to promote the acquisition of clinical skills in practice.^[27] Seven of the 20 articles reported modelling and observation as a useful strategy for students' skills development.^{[10,13,25,26,29-31]} Findings showed that supervisors displaying clinical skills in action, in real time, allow the students to gain insight into the supervisor's clinical reasoning and promote transference of theory to skills.^[10,25,30] One study emphasised the use of theory-based modelling, and the benefit of explaining theory behind the supervisor's action.^[26] Three studies reported modelling and observation of supervisor behaviour as crucial in acquiring professional behaviour, socio-emotional, interpersonal and communication skills and lifelong learning practice.^[10,29,30] Observational learning should incorporate real-time assistance of students in practice, and discussion and reflection on the theory behind the practice, resulting in the students' critical reflexivity.^[25]

Thirteen of the 20 articles reported feedback as a useful strategy in supporting students' skills development. Supervisors should assist in students' acquisition of the desired skills, as well as emphasise students' competences through feedback.^{[10-12,21,22,25-27,29-32,34]} Five studies emphasised that feedback strategies must evoke critical reflection of the students' observed behaviours within a practical task or over the course of the clinical education block to promote students' self-reflection and problem-solving through a critical lens.^{[11,26,27,29,31]} Three studies reported augmenting skills development within a non-clinical setting through a simulation strategy. Simulation can include workshops and tutorials with case studies, e.g. mannequin models.^[23,27,29] Six of the 20 articles reported that scaffolding can be used to account for and address variables beyond the students' scope, such as new clinical practice context, novel client diagnosis and the related therapeutic techniques required to treat and manage. Studies reported on supervisors employing grading, or task demand adaptations, modelling and hands-on facilitation of skills performance to assist the students' learning. Thereafter, the clinical tasks should be graded by decreasing adaptations, as the students' grow in confidence and competence of skills.^{[10,12,13,29,32,34]} Five articles reported peer support and peer learning as a useful strategy to aid teamwork development, professionalism, broaden knowledge and create a sense of universality, which aids in the learning process.^{[13,22,30,33,34]} Four articles reported the importance of an encouraging supervisor approach to the students' self-directed learning and reflection, as this promotes autonomy and self-efficacy in students.^{[11,13,21,25]} These studies note that an encouraging clinical supervisor matches the work task to the students' skills, while encouraging self-directed learning and discussions through allocating off-site work tasks such as theoretical readings.

 

Conclusion

This rapid review found some key factors that influence clinical supervision of occupational therapists. Most of the studies that were included echoed the need for a clear supervision protocol that acts as a guide to procedures, decision-making, managing roles and expectations. The review also found that there is a need for communication and feedback between the supervisor and OT student in placement. Findings showed that some of the strategies that can be employed by supervisors to develop the clinical and professional skills of students include modelling, observational learning, scaffolding, and peer learning. Furthermore, results of this review indicate that clinical supervision in the Global South context is influenced by the sociohistorical, economic and political forces at play, as some of the countries have entrenched histories of colonialism. Such histories cannot be overlooked in terms of how they promote certain ways of being and relating. Several studies noted that the power dynamics that exist between supervisor and student can be unproductive in their perpetuation of fear and feelings of inadequacy, while a partnering and nurturing relationship, with a recognition of the student as a novice, can counter this power imbalance.

Data availability. Data supporting this study are published in an institutional repository as Supplementary files 1-4: (https://doi.org/10.25375/uct.23623575.v2).

Declaration. None.

Acknowledgements. None.

Author contributions. AE and PM worked together to summarise a thesis student project submitted by JM, KP, SP, BR, KS and SD, who were supervised by AE. PM also worked with the students to devise a search strategy, searching through databases.

Funding. None.

Conflicts of interest. None.

 

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Correspondence:
P R Makwambeni
patricia.makwambeni@uct.ac.za

Received 2 November 2023
Accepted 30 September 2024