Managing Clinical Practice: The Trainer as Supervisor
(Part 4 of 5)
(July 2001)

The following was excerpted from JHPIEGO's newly revised Clinical Training Skills manual. This is the fourth of five parts on managing clinical practice.

Planning includes designing a schedule that allows participants adequate time to work with clients, and developing assignments and other learning activities for participants to complete in order to provide a positive learning environment in the clinic.

Even the best planning is not always enough to ensure a successful clinical practice experience. In the classroom, the trainer is able to control the schedule and activities
to a large extent. In the clinic, however, the trainer must always be alert to unplanned learning opportunities that may arise at any time, and be ready to modify the schedule accordingly.

Situation

You are conducting a course on reversible methods that has now moved into the clinical area. It is the first day in the clinic and the seven participants you are supervising are eager to begin working with clients as quickly as possible. You are going to supervise their interactions with clients and their service provision skills. After a short period of calm, you suddenly have four participants who need you to assist them at the same time: one is going to do basic counseling, another needs to give a Depo-Provera injection, another needs to perform a pelvic examination and the fourth needs to help a client who has returned complaining of nausea, breast tenderness and spotting between periods since beginning combined oral contraceptives 2 months ago. What do you do?

Write your response on a piece of paper and then compare your response with the one found at the end of this article.

The Trainer as Supervisor

In the role of supervisor, the trainer must monitor participant activities in the clinic so that: 

• each participant receives appropriate and adequate opportunities for skill practice,
• participants do not disrupt the efficient provision of services within the clinic or interfere with staff and their duties, and
• the care provided by each participant does not harm clients or place them in an unsafe situation.

The trainer must always be with participants when they are working with clients, especially when they are conducting initial counseling sessions and performing clinical procedures. Participants, in their eagerness to learn a new skill, often present certain methods in a persuasive manner while counseling a client. If the client chooses the IUD, the participant will have the opportunity to perform IUD insertion. The trainer must monitor the counseling session to be sure that information on all contraceptive methods is presented in an unbiased manner and that client screening is performed to prevent unnecessary examinations or provision of an unsuitable method. Once the trainer is comfortable with the counseling skills of the participants, the trainer may allow them to be more independent. 

Most trainers have more than one or two participants to supervise. Because the trainer cannot be with all of them at the same time, other methods of supervision must be used. 

• Participants must understand what they can do independently and what requires trainer supervision, so that they can keep busy when the trainer is involved with another participant. Participants should be made responsible for ensuring that they are supervised when necessary. The trainer, however, still holds the ultimate responsibility.
• Additional activities that require no direct supervision will give participants the opportunity to be actively engaged in learning when they are not with clients.
• Clinic staff also can act as supervisors if the trainer is confident of their clinical skills and ability to provide appropriate feedback. The possibility of having clinic staff supervise participants is another reason why the trainer should get to know the staff before the training begins.

During the initial visit to the clinic, the trainer can observe the skills of the staff members, and verify that they are competent, if not proficient, service providers. The trainer may also have the opportunity to assess their coaching skills. There may even be time to work with staff members to improve their skills so that they can serve as role models and support participant learning.

• The more participants there are in the clinic, the more the trainer relies upon the staff also to act as trainers. Nevertheless, the ultimate responsibility for each participant, including that of final assessment of skill competency, is the trainer's. For this reason, if multiple clinical sites are used during a course, a trainer must be assigned to each site.
• Because clinic staff usually are not involved in the classroom portion of a course, they do not have an opportunity to get to know the participants and their abilities before they arrive at the clinic. Therefore, it is a good idea to share such information with the clinic staff whenever they will have to take over a large part of the participant supervision. Clinic staff should also be encouraged to do an initial assessment of participants' skills before allowing them to work with clients so that they can feel confident that the participants are well prepared.
• Clinic staff should also be aware of the feedback the trainer would like to receive from them about participants.

  • Will it be oral, written or both? If written feedback is needed, the trainer should design an instrument or form to guide the clinic staff. The trainer should furnish a sufficient number of copies of the form and instruct the staff in its use. Samples 8-3 and 8-4 (in the Clinical Training Skills manual) are clinical practice feedback forms
    for preservice and inservice training, respectively. The trainer should develop a form that staff members can complete quickly and easily.
  • How frequently will feedback be provided? Daily? Weekly? Only at the end of training?
  • Should both positive and corrective feedback be provided?
  • Are there appropriate administrative channels through which the feedback should be transmitted? In some clinics, for example, staff members provide their feedback to the individual in charge of the clinic who then prepares a report for the trainer.
• When designing the feedback system, the trainer should keep in mind the time required to prepare and provide feedback. This will be extra work for the clinic staff, who already have a very busy schedule. It is best to keep the system as simple and easy to use as possible.

Situation Response

Obviously, you cannot be in four places at one time. One option is to ask staff members to supervise three of the participants while you supervise one. To feel comfortable doing this you will need to know the skills and abilities of the staff, which can only come through working and communicating with them before such a situation arises. Based on your assessment of their skills, you can decide which participant you will supervise. For example, you may want to supervise the participant performing the pelvic exam because that is a more advanced skill, especially if you have doubts about the staff's skills in this area. Or you may want to accompany the participant who will deal with side effects of combined oral contraceptives, if that is a new topic or one with which participants have had difficulty.

If you cannot use the staff to supervise some of the participants, you have a long and very busy clinical practice period ahead of you! You need to set priorities for the types of skills that need supervision. If participants have had considerable practice in one or two of the areas in question, those areas are not top priorities. The staff may need to go ahead and deal with those clients to avoid having them wait for a long period while you supervise other participants and clients. You could also set priorities by how long the activity will take. The Depo-Provera injection, for example, should only take a few minutes to give, so you could supervise that first and then move on to other participants. You will constantly be struggling throughout the clinical practice with this problem, however, if you cannot rely on the staff members to help supervise clients. It is worth investing some time to get to know them and their skills, and even help them improve, in order to have some help in the clinic.

For more information about conducting a clinical skills course, contact Rick Sullivan.

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