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Supervision training in healthcare: a realist synthesis

Supervision training in healthcare: a realist synthesis Supervision matters: it serves educational, supportive and management functions. Despite a plethora of evidence on the effectiveness of supervision, scant evidence for the impact of supervision training exists. While three previous literature reviews have begun to examine the effectiveness of supervision training, they fail to explore the extent to which supervi- sion training works, for whom, and why. We adopted a realist approach to answer the ques- tion: to what extent do supervision training interventions work (or not), for whom and in what circumstances, and why? We conducted a team-based realist synthesis of the super- vision training literature focusing on Pawson’s five stages: (1) clarifying the scope; (2) determining the search strategy; (3) study selection; (4) data extraction; and (5) data syn- thesis. We extracted contexts (C), mechanisms (M) and outcomes (O) and CMO configura- tions from 29 outputs including short (n = 19) and extended-duration (n = 10) supervision training interventions. Irrespective of duration, interventions including mixed pedagogies involving active and/or experiential learning, social learning and protected time served as mechanisms triggering multiple positive supervisor outcomes. Short-duration interven- tions also led to positive outcomes through mechanisms such as supervisor characteristics, whereas facilitator characteristics was a key mechanism triggering positive and negative outcomes for extended-duration interventions. Disciplinary and organisational contexts were not especially influential. While our realist synthesis builds on previous non-realist literature reviews, our findings extend previous work considerably. Our realist synthesis presents a broader array of outcomes and mechanisms than have been previously identified, and provides novel insights into the causal pathways in which short and extended-duration supervision training interventions produce their effects. Future realist evaluation should explore further any differences between short and extended-duration interventions. Educa- tors are encouraged to prioritize mixed pedagogies, social learning and protected time to maximize the positive supervisor outcomes from training. Keywords Supervision · Training · Health · Realist synthesis Charlotte E. Rees and Sarah L. Lee are joint lead authors. * Charlotte E. Rees charlotte.rees@monash.edu Extended author information available on the last page of the article 1 3 Vol.:(0123456789) 524 C. E. Rees et al. Introduction Supervision matters in health and human services. While definitions of supervision vary across the literature (Martin et al. 2017), Proctor’s popular model outlines three purposes of supervision: facilitating consistent and quality practice in supervisees (managerial func- tion), helping the development of supervisees’ knowledge, skills, attitudes and practices (educational function), plus providing supervisees with support and validation (restorative function) (Proctor 1987; Brunero and Stein-Parbury 2008; Dilworth et al. 2013; Gonsalvez and Milne 2010). See Box 1 for varying examples of definitions for supervision. An effec- tive supervisor skilfully provides feedback, teaches, fosters collaborative learning, under- stands the expectation of their supervisees and is organized (Gibson et  al. 2018). While supervision training is thought to enhance supervision effectiveness (Martin et  al. 2014; Fitzpatrick et  al. 2012; Dilworth et  al. 2013; Chu et  al. 2016), supervisors in health and human services consistently lack such training (MacDonald 2002; Spence et  al. 2001; Hoge et  al. 2011; Butterworth et  al. 2008). Despite a plethora of evidence on the qual- ity and effectiveness of supervision over the last 20  years (Spence et  al. 2001; Hill et  al. 2014; Newton et  al. 2016), scant evidence evaluating the impact of supervision training exists. Only three reviews exist in the literature focusing on supervision training (Milne et al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). While these reviews begin to offer insights into the effectiveness of supervision training, they largely focus on the positive outcomes of supervision training without explicitly discussing the complexities around how training interventions influence the quality or effectiveness of supervision. To address this gap in the supervision training literature, we conducted a realist synthesis to explore the extent to which supervision training works (or does not work), for whom and under what circumstances, how and why. Diversity and complexity of supervision training interventions While many argue for the importance of training to enhance supervision effectiveness (Kilminster and Jolly 2000), supervisors often carry out their supervision roles without any specific training (Hoge et  al. 2011). For supervisors who do experience supervision Box 1 Example definitions of supervision “Clinical supervision is a process of professional support and learning in which nurses are assisted in developing their practice through regular discussion time with experienced and knowledgeable colleagues…” (Brunero and Stein-Parbury 2008, p. 87) “Supervision is any activity where more experienced health professionals provide less experienced health professionals with opportunities that enable these health professionals to achieve learning, to receive support, and to improve the quality and safety of their practice” (Fitzpatrick et al. 2012, p. 462) “Supervision is a forum where supervisees review and reflect on their work in order to do better. Practitioners bring their actual work-practice to another person (individual supervision), or to a group (small group or team supervision), and with their help review what happened in their prac- tice in order to learn from that experience” (Caroll 2007, p. 36) “The formal provision, by approved supervisors, of a relationship-based education and training that is work-focused and which manages, supports, develops and evaluates the work of colleagues…” (Milne 2007, p. 439) “The term clinical supervision is defined as a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, and is acknowledged to be a life-long process…” (Martin et al. 2014, p. 201) 1 3 Supervision training in healthcare: a realist synthesis 525 training, they can experience a wide diversity in training with respect to content, mode, pedagogical strategies and duration. Supervision training content often focuses on the development of supervisor knowledge (e.g. definitions, models, methods, responsibilities, legal/ethical aspects) (Kilminster and Jolly 2000; Spence et al. 2001; Newton et al. 2016), and/or skills (teaching, assessment, feedback, counselling, leadership, interpersonal) (Kilminster and Jolly 2000; Hill et  al. 2014; McKellar and Graham 2017). Supervision training modes include face-to-face, online or blended approaches. Pedagogical strategies also vary including didactic (e.g. presentations, videotaped demonstrations), active (e.g. small group discussions) and/or experiential learning (e.g. role-play, feedback) (Spence et  al. 2001; Hoge et  al. 2011; Pollock et  al. 2017). The duration of supervision training ranges from one-off, short-term interventions (such as a 2-day workshop) to extended- duration interventions over many months that are punctuated by mini-interventions such as monthly supervision sessions (Spence et al. 2001). Although competency frameworks for supervision have been developed to guide supervision training (Health Workforce Australia 2014), some scholars argue that a lack of specificity still exists in terms of what and how supervision training should be conducted (Reiser and Milne 2014; Alfonsson et al. 2018). Furthermore, supervision training interventions have been criticised for lacking theoretical and evidence-based foundations (Kilminster and Jolly 2000). Therefore, we designed this realist synthesis to address these criticisms and gaps in the current literature. A realist approach to supervision training Given the diversity and complexity of supervision training interventions, a realist synthe- sis was used to better understand how and why supervision training interventions produce their effects. A realist approach is theory-driven, so facilitates the development and modi- fication of program theories accounting for how and why interventions work (or do not work) and for whom and when (Wong et al. 2012, 2016). This approach is underpinned by scientific realism, which asserts that it is not interventions that create change; rather, it is people who create change (Pawson and Tilley 1997). Interventions are thought to lead to outcomes through the operation of mechanisms, that is, the resources proffered by an inter - vention and the ways in which this influences participants’ reasoning (Dalkin et al. 2015). Furthermore, there is an appreciation that this complex relationship is context-dependent (Sholl et al. 2017; Ajjawi et al. 2018). Outcomes of any intervention can be affected by the range of conditions within any given setting, which are often sociocultural (Jolly and Jolly 2014). The basic premise is: what works for one person might not work for another; and what works in one circumstance might fail to work in another (Wong et al. 2016). While the context–mechanism–outcome (CMO) relationship is not necessarily straightforward or linear, contextual aspects are thought to trigger particular mechanisms in response to an intervention leading to particular outcomes (Jolly and Jolly 2014). See Box 2 for a glossary of key realist terms. Developing an initial program theory from non‑realist supervision training reviews Three supervision training reviews, one narrative and two systematic, have so far been pub- lished in the literature (Milne et  al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). While none of these employed realist approaches, nor did they include middle-range theory (MRT) specific to education apart from mentioning Kolb’s (1984) experiential learning (Milne et  al. 2011), we applied realist logic in our reading of these reviews to develop 1 3 526 C. E. Rees et al. Box 2 Glossary of realist terms Contexts can be described as: “the conditions that an intervention operates in (often but not exclusively sociocultural)” (Taylor et al. 2007, p. 28). Context can refer to individuals participating in programs, stakeholder interrelationships, institutional arrangements in which programs sit and/or wider cultural, economic and/or societal settings for programs (Pawson 2018). Mechanisms can be described as: “underlying entities, processes or structures which operate in particu- lar contexts to generate outcomes of interest” (Astbury and Leeuw 2010, p. 368). Mechanisms are typically hidden, sensitive to contextual variations and generative of outcomes (Astbury and Leeuw 2010). Outcomes can be described as the desired products of a program and/or the program’s observed prod- ucts (Yardley et al. 2015; Jolly and Jolly 2014). Context–mechanism–outcome configurations (CMOCs) can be described as heuristics employed “by some realists during analysis to identify the causal links between context, mechanism and outcomes” (Marchal et al. 2018, p. 83). Demi-regularities can be described as: “prominent recurrent patterns of contexts and outcomes… in the data” (Wong et al. 2013, p. 9). Program Theory can be described as: “a plausible and sensible model of how a program is supposed to work” (Bickman 1987, p. 5). A program theory therefore is an explanatory account of how a program works, under what circumstances and for whom (Astbury and Leeuw 2010). Such a theory-driven approach should include both the development of, and testing and refinement of, program theory (Astbury and Leeuw 2010). Middle-range theory (MRT) can be described as theory situated: “between the minor but necessary working hypothesis… and the all-inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behavior, social organization and social change” (Merton 1968, p. 83). MRT can be considered formal theory providing a bridge to existing knowledge about a topic (Marchal et al. 2018). an initial program theory (IPT: Fig.  1). We developed this IPT based on our identifica- tion of contexts, mechanisms, outcomes and context–mechanism–outcome configurations (CMOCs) for the supervision training interventions across the three papers. Firstly, studies included in these three reviews had several different contexts including health and human services (e.g. psychology, mental health, allied health), plus commercial contexts such Fig. 1 Initial program theory 1 3 Supervision training in healthcare: a realist synthesis 527 as sales and insurance (Milne et  al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Secondly, the supervision training interventions outlined within these three reviews were complex and diverse in terms of the: (a) content such as knowledge, skills and attitudes; (b) mode of delivery including face-to-face and online learning; (c) pedagogical strategies employed including theoretical and experiential learning; and (d) duration of the interven- tions including short (e.g. half-day) and extended durations (e.g. year) (Milne et al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Third, a variety of (mostly) positive outcomes were identified within the three reviews and related to supervisors (e.g. improved satisfac- tion, confidence, knowledge, skills) and supervisees (e.g. improved satisfaction and mental health). Fourth, we were also able to identify some mechanisms in the reviews to explain why interventions produced their effects e.g. supervision training interventions having an appropriate balance between didactic and experiential learning methods and extended durations enhancing engagement. Finally, we were able to identify two distinct CMOCs in two of the reviews: Within mental health supervision [C] clinical supervision training [I] leads to supervi- sor and supervisee development [O] through having a blend of pedagogic methods such as feedback, educational role-play and modelling [M] (Milne et al. 2011). • Within the workplace [C], supervision training [I] leads to improved supervisor knowl- edge and behaviour, plus enhanced supervisee mental health [O] through improved knowledge and behavioural modification [M] (Tsutsumi 2011). Study aim and research questions Although we have been able to identify contexts, mechanisms and outcomes and two CMOCs for supervision training interventions from previous reviews using realist logic, and develop an IPT, this current realist synthesis aimed to extend current literature reviews to develop a modified program theory (MPT). It aimed to review the published supervision training literature within health and human services to answer the novel research question: To what extent do supervision training interventions work (or not), for whom and in what circumstances, and why? Methods The review protocol registered on PROSPERO (CRD42018094186) and published (Lee et al. 2019) was underpinned by Pawson’s five stages of realist review: (1) clarifying scope; (2) searching for evidence; (3) study selection; (4) data extraction; and (5) data synthesis (Pawson et al. 2005). Although presented in a linear fashion, stages were conducted itera- tively with some overlap. The review methods and findings follow the RAMESES publica- tion standards for realist syntheses (Wong et al. 2013). Clarifying the scope A matrix identifying existing primary literature/empirical studies, literature reviews, search terms and their synonyms was created, generating numerous search terms. With the help of a medical librarian (see acknowledgements), pilot searches were conducted using several databases to test search terms (those identified as keywords in other 1 3 528 C. E. Rees et al. published supervision training outputs, plus synonyms familiar to our multidiscipli- nary team), Boolean operators and proximity searching. Note that our original scope for this realist synthesis was broad including health (e.g. medicine, nursing, allied health etc.) and human services (e.g. housing, disability, children services, youth and family services, alcohol and drug services, out of home care etc.), consistent with our fund- ing (Victorian Department of Health and Human Services). Furthermore, our scope was also broad in terms of interventions (e.g. workshops, online education, lectures), professions (e.g. nursing, physiotherapy, pharmacology, mental health), contexts (e.g. hospitals, universities, training centers, community services) and levels of learner (e.g. undergraduate students, postgraduate trainees, peers and colleagues). Searching for empirical evidence A final and comprehensive search of the literature was conducted in May 2018 by SLL, with input from the medical librarian and co-authors. Note that none of these final searches were limited by date. Key search terms and phrases included supervisor terms (e.g. supervisor, practice educator, clinical educator, preceptor) and training terms only (e.g. education, professional development, train-the-trainer). Given the breadth of our search, we did not include search terms relating to interventions, professions, contexts or levels of learner, as advised by our medical librarian. For a full list of search terms see the protocol (Lee et  al. 2019). Key terms were combined with proximity search- ing, Boolean operators, truncations and asterisks. Furthermore, searches were adapted to meet the operative requirements of each database including: Educational Resources Information Center (ERIC, ProQuest); Australian Public Affairs Information Service (APAIS, Informit); Social Services Abstracts (ProQuest); Scopus; PsycINFO (Ovid); MEDLINE (Ovid); and Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus, Ebsco). An example of a CINAHL search strategy is included in Box 3. Citations and reference lists of included studies were hand searched to identify addi- tional relevant studies. The first search elicited 15,676 outputs across all databases. Once duplicate results were removed, 11,764 outputs remained. All outputs were exported to Covidence soft- ware (© Covidence 2019) for management. The searching and selection process is sum- marised in the PRISMA diagram (see Fig. 2). Inclusion and exclusion criteria are shown in Table  1. Given the number of outputs identified, non-peer-reviewed outputs were excluded. Box 3 Search strategy example of CINAHL search (supervisor* OR mentors OR mentor OR mentoring OR instructor* OR “placement educator*” OR “practice educator*” OR trainer* OR preceptor OR preceptors OR “clinical teacher*” OR “clinical educator*” or “fieldwork educator*”) N2 (training* OR education OR educating OR workshop*) Supervision N1 (training OR education OR educating OR workshop*) “train the trainer*” (“professional development” OR “faculty development” OR “personal development” OR CPD) N2 (supervisor* OR mentors OR mentor OR mentoring OR instructor* OR “placement educa- tor*” OR “practice educator*” OR trainer* OR preceptor OR preceptors OR “clinical teacher*” OR “clinical educator*” OR “fieldwork educator*”) 1 3 Supervision training in healthcare: a realist synthesis 529 Fig. 2 PRISMA Table 1 Inclusion and exclusion criteria Inclusion criteria Exclusion criteria Relate to one or more of the research questions Literature relating to research supervision Relevant population: literature must relate to either health/health- care, housing, children services, youth and family services and/or mental health disciplines within the health and human service workforces Relevant intervention: literature must relate to supervision train- ing interventions Literature must be written in the English language Peer-reviewed outputs only Primary/empirical research only Study selection and appraisal All authors (except EH) conducted initial assessments of outputs’ relevance using Covi- dence. Each analyst first participated in a calibration exercise of ten titles and abstracts using the inclusion criteria, with subsequent team-based discussions, before analyzing their own set of titles and abstracts. Each author (except EH) then screened a roughly equal 1 3 530 C. E. Rees et al. portion of the titles and abstracts of studies retrieved using the search strategy (and those retrieved from hand searched references) against the inclusion criteria (see Table  1). Any ambiguities at this stage (i.e. outputs selected as ‘maybe’ in Covidence) were checked by a second independent researcher and resolved through discussion (SLL). Five percent of the 11,764 outputs examined for relevance was therefore double-checked at this stage (SLL) (Brennan et al. 2014). Following this initial assessment of relevant titles and abstracts, 77 outputs remained. The full text of these outputs were retrieved and all authors assessed a roughly equal por- tion of outputs for rigour, after first participating in a second calibration exercise involv - ing two full-text outputs, with consequent team-based discussions. Rigour was determined to understand whether the methods used to generate data were credible and trustworthy (Abrams et al. 2018). All authors checked rigour using either the Critical Appraisal Skills Programme (CASP) qualitative checklist (for qualitative or mixed methods studies) (Criti- cal Appraisal Skills Programme 2018), or the Medical Education Research Study Quality Instrument (MERSQI) (for quantitative studies) (Cook and Reed 2015; Reed et al. 2009). At the same time as assessing rigour, we also reexamined relevance based on the full-text outputs, a process which we termed ‘realist relevance’. This meant that the outputs were judged in terms of whether they could contribute to the development of our IPT (Wong et  al. 2013; Abrams et  al. 2018). Assessment of ‘realist relevance’ was based on a 0–3 scale where 0 = the article lacked richness to enable the identification of contexts (C), mechanisms (M), outcomes (O) or context–mechanism–outcome configurations (CMOCs) and could therefore not help in the development of our IPT. At the other end of the scale, a paper received 3 = the article was sufficiently rich to identify CMOCs and could help develop our program theory. Finally, each paper was given an overall judgement (include, exclude, borderline) for rigour and realist relevance combined. Any outputs assessed as borderline for rigour and relevance (approximately 57%) were checked by a second author and any disagreements resolved through discussion (SLL and EH) (Brennan et al. 2014). The final sample of included outputs was 29. Data extraction All authors (except VE and BW) extracted data after a third calibration exercise involv- ing analysts’ extraction of two full-text outputs, with subsequent team-based discussions. The data extraction of the 29 outputs included: study characteristics (e.g. publication year, study methodology); contexts (e.g. study setting, profession, level of supervisor experi- ence, country); intervention characteristics (e.g. content, mode, pedagogical strategies, duration); types of participants (e.g. clinical teachers); mechanisms and outcomes (note that outcomes and/or mechanisms could be positive or negative and pertain to supervisors or supervisees); CMOCs; and MRT. Contexts (C), Mechanisms (M) and Outcomes (O) and CMOCs for each supervision training intervention were highlighted on the 29 outputs and notes added by the data extractors. These highlights and notes were then transferred to tables using Microsoft Word (Microsoft, Windows 10) collating C, M, and Os and CMOCs both within and across our final sample. Note that during this process we labelled out- comes and mechanisms underpinning those outcomes as either positive (+) or negative (-). Inspired by other realist syntheses (Abrams et al. 2018), in order to elicit this informa- tion we made interpretations of meaning (e.g. does the relevant text provide sufficient data that could be interpreted as operating as contexts, mechanisms and/or outcomes?). Seven 1 3 Supervision training in healthcare: a realist synthesis 531 outputs (24%) were double-checked by a second extractor (mostly EH) at this data extrac- tion stage, with any discrepancies resolved through discussion (SLL). Data synthesis To synthesise the large amount of extracted data, we first divided our data into two cat- egories based on the duration of interventions (either short or extended durations), given that intervention duration was flagged as an important intervention component and a mechanism underpinning positive outcomes in our IPT (Fig. 1). Note that short durations were defined as one-off interventions or interventions with multiple sessions but within a restricted time period (e.g. less than 1  week). Conversely, interventions with extended durations were defined as those conducted over many months (and sometimes years), with extended time periods between multiple sessions (e.g. monthly). Microsoft word tables including CMOCs with supporting illustrative quotes from the outputs were used for this data synthesis stage. Led by CER, four authors (CER, SLL, EH and CP) exam- ined the data in these tables to identify demi-regularities (i.e. recurrent CMOCs) (Lee et al. 2019) across the 29 outputs with 139 original CMOCs identified across interventions with short (87 CMOCs) and extended durations (52 CMOCs). Inspired by other realist synthe- ses (Abrams et  al. 2018), we asked questions like: is this CMOC found elsewhere in the same or other documents? How does this CMOC interplay with our IPT? How might this CMOC develop our program theory? Note that at this stage, CMOCs that were considered tangential to these demi-regularities or did not contribute to our MPT were removed from the final tables presented in this paper, leaving 74 final CMOCs (with 42 CMOCs for short- duration interventions, and 32 CMOCs for extended-duration interventions). Results Following the assessment of rigour and realist relevance, 29 outputs remained in the final synthesis based on 28 studies; one study being presented across two outputs (Sandau et al. 2011; Sandau and Halm 2011). The final sample of outputs consisted of eight qualitative, eleven quantitative and ten mixed methods studies. Studies were conducted in various countries including the USA (n = 10), Australia (n = 5), UK (n = 3), Jordan (n = 2), Swe- den (n = 3), Canada (n = 2), Netherlands (n = 1), Taiwan (n = 1) and Pakistan (n = 1), with one paper conducted across multiple counties (Myrick et  al. 2011). Study interventions included face-to-face only (n = 24), online only (n = 4) and blended approaches including face-to-face and online components (n = 1). Interventions were either of short (n = 19) or extended durations (n = 10). There was a vast array of disciplines involved in the final sam- ple including nursing (n = 9), medicine (n = 2) and allied health professions (n = 14), with some outputs including multiple disciplines (n = 4) (e.g. Carlson and Bengtsson 2015). In keeping with our IPT, data extraction and synthesis is presented separately for short (Table 2) and extended-duration interventions (Table 3). Short‑duration supervision training interventions Short-duration supervision training interventions typically focused on learning out- comes relating to supervisory knowledge and skills (content), were delivered face-to- face (mode) and employed multiple approaches such as didactic (e.g. presentations, 1 3 532 C. E. Rees et al. 1 3 Table 2 Data extraction for short-duration interventions References Study methods Intervention Settings Middle-range theories Al-Hussami et al. (2011) Quantitative Knowledge and skills Nursing King’s theory of goal attainment Experimental F2F Clinical instructors (King 1997) 68 registered nurses (RNs) ran- PS: didactic and active learning Hospitals domly assigned to experimental 1 week with 4-h sessions (number Jordan (n = 30) or control group (n = 38) of sessions and time between Objective assessment of their sessions unknown) precepting knowledge Busari et al. (2006) Quantitative Knowledge and skills Medicine: paediatrics, and obstet- None Quasi-experimental F2F rics and gynaecology 27 medical resident preceptors PS: not disclosed Preceptors assigned to an experimental 2 days Teaching hospitals (n = 14) or control group (n = 13) Netherlands Self-perception of the workshop and supervisees’ assessment of preceptors’ teaching Carlson and Bengtsson (2015) Qualitative Knowledge and skills Multiple disciplines: nursing, Adult learning theories (not Interpretive F2F occupational therapy and bio- specified) 27 focus group participants PS: didactic, active and EL medical science Self-perception of the intervention 40 h Clinical preceptors and self-assessment of learning University outcomes Southern Sweden Supervision training in healthcare: a realist synthesis 533 1 3 Table 2 (continued) References Study methods Intervention Settings Middle-range theories Clipper and Cherry (2015) Quantitative Knowledge and skills Nursing Boychuk Duchscher’s theory Quasi-experimental Blended (5 online modules and a Preceptors of transition shock (Boychuk 18 trained and 41 untrained nurs- F2F course) Acute care hospitals Duchscher 2009) ing preceptors PS: didactic, active and EL USA Supervisees’ assessment of 3-h online modules and 1-day preceptors’ teaching and self- course assessment of their own student- to-nurse transition experience Cox et al. (2017) Quantitative Knowledge Pharmacology Adult learning principles (not Experimental, longitudinal Online Adjunct and specified) 187/202 pharmacists completed PS: didactic full-time faculty preceptors, and the evaluation 5–8 min in each video episode (12 novice preceptors Self-assessment of learning episodes in total) Colleges outcomes USA Eckstrom et al. (2006) Qualitative Knowledge and skills Internal medicine None Quasi-experimental, longitudinal F2F Ambulatory preceptors pre/post-test PS: didactic and EL University hospital, Veterans hos- 24 participants (experimental) and half-day pitals, and community sites 44 (control group) USA Supervisees’ assessment of precepting quality and supervi- sors’ self-assessment of learning outcomes Ford et al. (2013) Mixed methods Skills Nursing and midwifery Experiential learning (not speci- Pre- and post-test F2F Junior and senior preceptors fied) 93 nurses and midwives PS: active and EL A 400-bed tertiary referral hospitalReflective practice (not specified) Self-assessment of learning out- 1 day Australia comes and perceptions of being preceptors 534 C. E. Rees et al. 1 3 Table 2 (continued) References Study methods Intervention Settings Middle-range theories Gillieatt et al. (2014) Mixed methods Knowledge and skills Multiple professions: medicine, None Pre- and post-intervention survey F2F nursing and allied health 90/94 participants completed the PS: didactic and active learning Experienced and novice preceptors pre and post surveys 1 day Government and private organisa- Self-assessment of learning tions outcomes Australia Henderson et al. (2006) Qualitative Knowledge and skills Nursing None Longitudinal F2F Novice preceptors 36 registered nurses PS: didactic, active and EL Acute tertiary referral center Subjective assessment of learning 2 days Australia outcomes Hook and Lawson-Porter (2003) Qualitative Knowledge and skills Allied health None Triangulation F2F Novice preceptors 22 allied health professionals PS: didactic and active learning Clinical setting Perceptions of the workshop and 3 days UK self-assessment of learning outcomes Lee et al. (2017) Qualitative Skills Nursing Gagné’s information processing Experimental F2F Novice preceptors theory (Gagné 1985) 13 nurse preceptors (NPs) and 11 PS: didactic and active learning Teaching hospitals new graduate nurses (NGNs) 10 h Taiwan Objective assessment of learning outcomes, self-assessment and supervisees’ assessment of learning outcomes, and percep- tions of the workshop Supervision training in healthcare: a realist synthesis 535 1 3 Table 2 (continued) References Study methods Intervention Settings Middle-range theories McChesney and Euster (2000) Mixed methods Knowledge and skills Social work Knowles’ adult learning theory Quantitative scales and qualitative F2F Agency based social work field (Knowles 1972) questions PS: didactic and active learning instructors 22 educators 4 h Agencies Perceptions of the course and USA self-assessment of the learning outcomes Methot et al. (1996) Quantitative Skills Mental health None Longitudinal F2F Supervisors 1 manager, 4 supervisors, 7 direct PS: didactic, active and EL A residential facility for persons care staff, and 16 clients 3-h presentation and video view- with developmental disabilities Objective assessment of learning ing (duration of follow-up meet- UK outcomes ing not disclosed) Murphy (2014) Quantitative Knowledge and skills Physical therapy Benner’s novice-to-expert model Survey F2F Clinical educators (Benner 1984) 302 physical therapists PS: EL Workplace is not mentioned Kolb’s experiential learning (Kolb Perceptions of the workshop and 1 day Canada 1984) self-assessment of expected learning outcomes Quirk et al. (1998) Quantitative Knowledge and skills Multiple professions: medicine, None Pre- and post-test, and follow-up F2F nursing, psychology and mid- 223 healthcare professionals PS: didactic, active and EL wifery Self- and objective-assessments of 1 day Clinician preceptors learning outcomes, and percep- Workplaces not disclosed tions of the workshop USA 536 C. E. Rees et al. 1 3 Table 2 (continued) References Study methods Intervention Settings Middle-range theories Sandau et al. (2011); Sandau and Mixed Methods Knowledge and skills Nursing None Halm (2011) Quasi-experimental: pre- and F2F Novice preceptors Novice-to-expert framework post-test with qualitative com- PS: didactic and active learning Hospital (Benner 1984) ments 8 h USA Adult learning theory (not speci- 131 preceptors (experimental) and fied) 74 (control group) Self-assessment of the learning outcomes, perceptions of the workshop, and supervisees’ per- ceptions of their orientation Sayani et al. (2017) Mixed methods Knowledge and skills Midwifery None Quantitative: pre- and post-test F2F Novice preceptors and qualitative interviews PS: not disclosed Community 50 midwives 2 days Pakistan Objective assessment of learning outcomes, perceptions of men- toring and willingness to precept Taylor et al. (2007) Mixed methods Knowledge Pharmacology None Likert scale, free-text questions Online Rural pharmacy preceptors and focus groups PS: didactic and active learning Community and hospital 15 pharmacist preceptors 10–20 h Australia Perceptions of the programme and self-assessment of learning outcomes F2F face-to-face; PS pedagogical strategies; EL experimental learning; h hours Supervision training in healthcare: a realist synthesis 537 1 3 Table 3 Data extraction for extended-duration interventions References Study methods Intervention Settings Middle-range theories Halabi et al. (2012) Qualitative Knowledge and skills Nursing Kolb’s experiential learning (Kolb Longitudinal design F2F Nursing preceptors 1984) 12 nursing preceptors PS: didactic, active and EL Governmental and private hos- Dewey’s theoretical ideas of Self-assessment of learning 1-week teaching phases with pitals education as integration between outcomes monthly 5-h meetings in Jordan theory, practice, reflection and between action (Dewey 1964) Schön’s reflective practice (Schön 1987) Milne and Westerman (2001) Quantitative Skills Mental health nursing Kolb’s experiential learning (Kolb Observational and longitudinal F2F Supervisor 1984) design PS: active and EL Community 1 consultant, 1 supervisor, and 3 Hourly weekly meetings over an UK supervisees 8-month period Objective assessments of learning outcomes Myrick et al. (2011) Qualitative Skills Nursing Learning theory (non-specified) 9/18 preceptors participated in Online Preceptors Experiential learning (non- semi-structured interviews PS: didactic and active learning 4th year of undergraduate nursing specified) Perceptions of the e-learning 5 months program technology and self-assessment Australia, Brazil, China, Hong of learning outcomes Kong, Pakistan, UK and USA Ögren et al. (2008) Qualitative Knowledge and skills Psychotherapy Psychodynamic theory (not speci- Longitudinal design F2F Novice preceptors fied) 3 facilitators and 6 novice supervi- PS: didactic, active and EL Workplace not disclosed sors 2 years (theoretical seminars 2-h Sweden Self-assessment of group weekly and group supervision 2-h weekly) 538 C. E. Rees et al. 1 3 Table 3 (continued) References Study methods Intervention Settings Middle-range theories Paulson and Casile (2014) Mixed methods Knowledge and skills Rural mental health None Pre- and post-test survey F2F Rural supervisors 40 nursing preceptors PS: didactic and EL Rural areas Self-assessments of learning 1-day supervision workshop plus USA outcomes and mental state 6-month monthly follow-up peer group supervision training sessions Rogers and McDonald (1992) Quantitative Knowledge and skills Social work Schön’s reflective practice (Schön Quasi-experimental F2F Field instructors 1987) 25 field instructors (experimental) PS: didactic, active and EL Workplace not disclosed and 25 (control group) 20 h across 10 weeks Canada Objective assessment of learning outcomes Seo and Engelhard (2014) Mixed methods Knowledge and skills Physical therapy Knowles’ adult learning theory Quasi-experimental Online Clinical instructors (Knowles 1990) 21 physical therapist clinical PS: active learning A public university Self-regulated learning (not instructors in experimental 9 weeks USA specified) group and 24 in control group Self-assessment of learning outcomes Sevenhuysen et al. (2013) Mixed methods Skills Physiotherapy Peer-assisted learning (not speci- Participatory research F2F Clinical educators fied) 14 clinical educators PS: didactic and active learning Five hospital campuses and com- Self-assessment of learning 2 h for each workshop (a series of munity health and rehabilitation outcomes and perceptions of the 4 workshops with unclear tim- centres workshop ings in-between) Australia Supervision training in healthcare: a realist synthesis 539 1 3 Table 3 (continued) References Study methods Intervention Settings Middle-range theories Sundin et al. (2008) Quantitative Knowledge and skills Psychotherapy Proctor and Inskipp’s theory Quasi-experimental F2F Novice supervisors (Proctor and Inskipp 2001) 21 supervisors and 6 facilitators PS: didactic and EL Workplace not disclosed Self-assessment of learning 2 years (group supervision is 2 h Sweden outcomes and perceptions of weekly: total 140 h duration) supervisor styles Tebes et al. (2011) Quantitative Knowledge and skills Social work Shulman’s interactional theory of Quasi-experimental: pre- and post-F2F Clinical supervisors clinical supervision (Shulman intervention follow-up with no PS: didactic and active learning Non-profit behavioural health 1991, 1993, 2005) comparison group 7-month duration (approximately agencies 81 social workers 28 h or 5 days) USA Perceptions of the training, self- assessment of learning outcomes 540 C. E. Rees et al. videos), active (e.g. group discussions, case studies, reflection activities) and experi- ential learning (e.g. role plays, feedback). Although MRTs underpinning short inter- ventions were often absent or not specified in the outputs, a range of theories were identified, the most common of which were adult learning theories (Knowles 1972), experiential learning (Kolb 1984) and the novice-to-expert model (Benner 1982). Ten demi-regularities pertinent to our developing program theory were identified from the wide-ranging CMOCs identified in the extraction phase, with eight demi-regu- larities highlighting interventions’ positive outcomes and two demi-regularities illustrat- ing interventions’ negative outcomes (see Table  4). In terms of the positive outcomes, all but one of the identified demi-regularities related to supervisor outcomes: Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced improved satisfaction with training [+ O] (Hook and Lawson-Porter 2003; McChesney and Euster 2000; Murphy 2014); improved supervisory confidence [+ O] (Carlson and Bengtsson 2015; Ford et al. 2013; Taylor et al. 2007); improved supervisory engagement [+ O] (Cox and Araoz 2009; McChesney and Euster 2000; Taylor et al. 2007) and improved supervisory knowledge and practices [+ O] (C Cox et al. 2017; Ford et al. 2013; Gillieatt et al. 2014; Henderson et al. 2006; Hook and Lawson-Porter 2003; Lee et  al. 2017; Methot et  al. 1996; Murphy 2014) through mixed pedagogical strategies including active and/or experiential learning [+ M]. • Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced improved supervisory practices [+ O] through improved knowledge, skills and/or attitudes [+ M] (Carlson and Bengtsson 2015; Taylor et al. 2007). Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced improved supervisory practices [+ O] through improved confidence and/or self-efficacy [+ M] (Carlson and Bengtsson 2015; Eckstrom et al. 2006). • Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced improved supervisory satisfaction, knowledge, practices [+ O] through posi- tive social relationships [+ M] (Gillieatt et  al. 2014; Henderson et  al. 2006; Hook and Lawson-Porter 2003; McChesney and Euster 2000). The remaining demi-regularity relating to positive outcomes spoke to supervisee outcomes: • Healthcare supervisors [C] undergoing short-duration supervision training [I] helped improve supervisee development and well-being (e.g. retention) [+ O] through struc- tured training [+ M] (Clipper and Cherry 2015; Sandau et al. 2011). The demi-regularities that resulted in negative outcomes pertained only to supervi- sor-related outcomes: Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced no improvements in supervisory skills [− O] through lack of engagement in training or reinforcement of training [− M] (Busari et  al. 2006; Eckstrom et  al. 2006; Quirk et al. 1998). Healthcare supervisors [C] undergoing short-duration supervision training [I] experi- enced poor supervisor engagement in training [− O] through insufficient protected time [− M] (Hook and Lawson-Porter 2003; Sandau and Halm 2011; Sayani et al. 2017). Based on these demi-regularities we developed a modified program theory (MPT) for short-duration interventions (Fig. 3). 1 3 Supervision training in healthcare: a realist synthesis 541 1 3 Table 4 CMOCs for short-duration interventions Reference CMOC Illustrative quote (page number) Busari et al. (2006) Medical residents [C] who attended the 2-day teaching workshop [I] did not “The post-workshop ratings, however, showed no significant difference show significant improvement in teaching ability [− O] because of incomplete in teaching ability between the experimental group and the control participation in the workshop [− M] group. Possible explanations for this finding could be the consider - able drop-out… ill health, maternity leave, graduation, external clini- cal rotations and incomplete participation in the workshop.” (p. 140) Carlson and Bengtsson Participants [C] undergoing the CPD course [I] expressed their growth in self- “The participants explained, in interviews and reflective journals, (2015) confidence in relation to the preceptor role [+ O] through multiple learning how they had gained self-confidence in relation to the preceptor role activities [+ M] through the different learning activities.” (p. 4) Preceptors [C] undergoing the CPD course [I] expressed that they would “It was also described that the new knowledge and skills would be put implement new educational models for students [+ O] due to newly acquired to use to… implement new educational models for students.” (p. 4) knowledge and skills [+ M] Preceptors [C] undergoing the CPD course [I] improved precepting behaviours “Reflective journals as well as discussions in the focus groups dis- [+ O] as the preceptors had experienced an increased confidence in their closed how participants experienced an increased trust in their abili- abilities as preceptors [+ M] ties as preceptors. This was described as having gained inner strength and the courage to try new approaches to precepting.” (p. 4) Preceptors [C] undergoing the CPD course [I] improved preceptor behaviours “After participating in the course they [preceptors] expressed how the [+ O] as they had gained new knowledge and improved communication skills new knowledge and the improved communication skills helped them [+ M] to be better prepared and courageous in situations they perceived as difficult.” (p. 4) Preceptors [C] undergoing the CPD course [I] shifted their didactical approach “The preceptors perceived that they had gained more understanding of from teacher-oriented to learner-oriented [+ O] as they had gained more how they could use reflection as an educational tool working with the understanding of how they could use reflection [+ M] students. They explained that their didactical approach had shifted from teacher-oriented to learner-oriented.” (p. 5) Clipper and Cherry Nurse graduate supervisors [C] who participated in a preceptor-training pro- “A structured preceptor-training program may contribute to an (2015) gram [I] may contribute to an improved transition to practice and improved improved transition to practice and improved first-year retention rates first-year retention rates of NGRNs [+ O] due to structured preceptor-training of NGRNs.” (p. 448) program [+ M] 542 C. E. Rees et al. 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) Cox et al. (2017) Given the various learning styles of each pharmacist preceptor [C], the online “Given the diversity of individual approaches to learning, we believe video mini-series [I] reached a broader audience [+ O] because the mini- blended learning has the potential to more successfully reach a series provide content in both written and video formats [+ M] broader audience. Although this cannot be definitively said, the mini- series did provide content in both written and video formats.” (p. 9) Pharmacist preceptors [C] undergoing the online video mini-series [I] actively “By requiring participants to think about a particular situation and how participated in reflection questions [+ O1] enabling them to apply the content it would apply to them or their practice, they were able to process the to their preceptor role [+ O2] through the content relating to their experiences educational content in a way that enabled them to more easily apply or hypothetical situations [+ M1] the content in their role as a preceptor.” (p. 10) Eckstrom et al. (2006) Internal medical preceptors [C] who participated in the 1-min preceptor (OMP) “Faculty who participated in our workshop felt that they increased their workshop [I] experienced increased use of the OMP teaching skills over the use of the OMP teaching skills over the next 6 months. Faculty per- next 6 months [+ O] because their self-efficacy helped the continued perfor - ception of self-efficacy is critical to continued performance of newly mance of newly learned skills [+ M] learned skills.” (p. 412) Internal medical preceptors [C] who have participated in the 1-min preceptor “Because faculty are habituated to a particular teaching practice, they (OMP) workshop [I] fell back to their previous patterns of supervisory behav- may make early changes after what they consider successful faculty iours [− O] if their new skills were not reinforced [− M] development intervention, and then fall back into previous patterns of behaviour if the new skills are not reinforced.” (p. 413) Ford et al. (2013) Nursing and midwifery preceptors [C] participating in a 1-day workshop [I] “There is evidence of an interconnectedness between the development increased their preceptorship confidence, knowledge and skills [+ O] based of knowledge and skills of the nurses and midwives and the enabling on the practice development approach [+ M] strategies that are utilised in the delivery of the program. Once again, these features of the program are also features of a Practice Develop- ment approach.” (p. 12) Gillieatt et al. (2014) Health professionals [C] participating in a 1-day training program [I] reported “The challenges associated with the simultaneous application of the that their self-rated supervisory skills had changed as a result of the training three functions were explored through practice exercises using sce- [+ O] through engagement with practical exercises [+ M] together with feed- narios and through feedback from peers and trainers” (p. 4) back from peers and colleagues [+ M] Health professionals [C] participating in a 1-day training program [I] reported “… reported that their skills had definitely changed (41%) or mostly that their supervisory knowledge and skills had improved [+ O] through changed (42%) post-training… feeling empowered, confident and increased confidence [+ M] enthusiastic; being more comfortable in the role of supervisor and having increased knowledge and skills.” (pp. 5–6) Supervision training in healthcare: a realist synthesis 543 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) Henderson et al. (2006)RN preceptors [C] undergoing the 2-day preceptor training [I] increased “One of the benefits perceived by the preceptors was their opportunity knowledge about the preceptor role [+ O] due to the benefit of learning from to learn from others. Some found that they learned from both new others [+ M] graduates and more experienced transfers.” (p. 133) Hook and Lawson- Multiprofessional field work educators [C] involved in a 3-day fieldwork educa- “…practitioners identified that their practice with students had changed Porter (2003) tor course [I] felt their educator and practitioner roles had changed positively positively, being more reflective with the use of learning styles [+ O] due to being more reflective on learning styles and supervision [+ M] and supervision skills. Some felt that they had changed in areas of practice within their role as a practitioner and not just within their educator role.” (p. 535) Multiprofessional field work educators [C] involved in a 3-day fieldwork educa- “…most practitioners found the pressures of their workload and tor course, plus reflective portfolio assignment [I] reported difficulty finishing domestic life difficult to balance with the pressures of completing an assignment and course requirements [− O] because their service managers assignment… not all participants were given study time to enable provided insufficient study time after the face-to-face session [− M] them to complete their portfolio.” (p. 535) Multiprofessional field work educators [C] involved in a 3-day fieldwork educa- “…the multi-professional and therapy-led nature of the course was tor course [I] were satisfied with the course [+ O] due to the opportunity to well received. Participants welcomed the opportunity to share and share and discuss with other health professions [+ M] integrate with other professionals and experience a programme that was relevant to their practice.” (p. 535) Multiprofessional field work educators [C] involved in a 3-day fieldwork educa- “Some used their mentors in the early stages of the assignment to tor course [I] were able to clarify ideas and consolidate work [+ O] because clarify ideas and help guide their thinking. Others used their mentors they engaged with their post-course mentor well [+ M] to consolidate their work and gain reassurance that their reflections were addressing the learning outcomes appropriately.” (p. 535) Lee et al. (2017) The nursing preceptors [C], after taking the training course including video “On the basis of the results of the focus group interviews with the NPs, instruction and reflections [I] experienced a strong pedagogical effect [+ O] the current authors thought that using nine instructional events… because multiple teaching skills were presented in the course rather than along with video instruction and reflections would have a strong using lectures alone [+ M] pedagogical effect.” (pp. 226–227) The nursing preceptors [C] who participated in the training course [I] had their “The reflection quizzes were all based on the content of the courses, learning reinforced [+ O] after taking the course content-based quizzes [+ M] reinforcing their influence.” (p. 227) 544 C. E. Rees et al. 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) McChesney and Euster Social work fieldwork instructors [C] involved in a 4-h workshop [I] felt the “Active learning methods were perceived to promote feelings of high (2000) workshop had high productivity, involvement and safety [+ O] because of the productivity, high involvement and high safety for participation use of active learning methods [+ M] among field instructors.” (p. 201, abstract) “Brief lectures and discussion related to materials provided in the Social work fieldwork instructors [C] involved in a 4-h workshop [I] partici- pated in active discussion and effective interaction [+ O] due to brief lectures resource guide appeared to stimulate active discussion and effective and discussion related to resource material [+ M] interaction.” (p. 212) Social work fieldwork instructors [C] involved in a 4-h workshop [I] engaged “Case vignettes and accompanying questions served to stimulate in critical thinking and helpful discussion [+ O] due to prompts for reflective critical thinking and helpful discussion. The cases promoted discus- practice [+ M] sion not only about specific practice dilemmas, but also about field instructor’s own experiences with similar situations and how they had been resolved.” (p. 213) Social work fieldwork instructors [C] involved in a 4-h workshop [I] were satis- “The small size of the seminar groups provided the opportunity for fied [+ O] and able to participate in constructive group discussion [+ O] due constructive group discussion. Most of the seminar participants to the interactions amongst small group/small participant numbers [+ M] actively engaged in discussion of field practicum issues.” (p. 213) Social work fieldwork instructors [C] involved in a 4-h workshop [I] were satis- “Each group read and discussed among themselves the ethical and fied with and enjoyed discussion about a topic [+ O] due to the interaction legal dilemmas… Participants appeared to enjoy the interaction and with peers and exchange of views in a peer teaching activity [+ M] exchange of views that this teaching method provided. They studied the article section assigned to them and lively discussion ensued.” (p. 213) Methot et al. (1996) Mental health supervisors [C] experiencing training videos demonstrating “… it takes little time to verify on-the-job use of the performance feed- 10 components of a formal supervision meeting [I] achieved considerable back skills by trained supervisors. A great deal of behaviour change behaviour change at the direct staff and client levels [+ O] as the supervisors at staff and client levels can be achieved with a small amount of time and managers only needed to spend little time watching the videos to verify invested in appropriate training at upper levels in the organization.” their on-the-job use of performance feedback skills [+ M] (p. 21) Mental health supervisors [C] experiencing training videos [I] showed variabil- “The variability in behavior levels for most subjects is apparent and ity in behaviour [− O] through the amount and types of other duties involved should be qualified in terms of the amount and types of other duties in managing, supervising and delivering direct care to developmentally involved in managing, supervising and delivering direct care… disabled clients [− M] Because of these additional duties… one would not expect to find stable data on delivery of contingent consequences across observa- tions.” (p. 21) Supervision training in healthcare: a realist synthesis 545 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) Murphy (2014)) Physical therapy clinical educators [C] participating in a hands-on workshop “role play… [where] participants formed triads, with one person taking [I] were satisfied with the workshop [+ O] and had an increased perception of the student role, one the educator and one the observer… role-play readiness and comfort to provide student learning [+ O] through role playing was the most valuable thing learned.” (p. 338) communication and conflict resolution [+ M] Quirk et al. (1998) Community health preceptors [C] attending a 1 day face-to-face workshop [I] “Retention rates should decrease as complexity of the initial learning decreased the retention rate of teaching behaviours over time [− O] when increases. In this regard one would expect the use of the teaching complexity of initial learning increased [− M] behaviours presented at the workshop might decrease over time more so than familiarity with the concepts.” (p. 707) Community health preceptors [C] undergoing a 1 day face-to-face short devel- “Further studies are needed to see whether a booster session or incen- tives might help preceptors to maintain appropriate use of teaching opment workshop intervention using the education planning process [I] might maintain their appropriate use of teaching behaviours [+ O] because a booster behaviours… This would be especially important in situations where session or incentive might reinforce learning and knowledge [+ M] the faculty intervention is short and the expected change in behaviour is complex.” (p. 707) Preceptors from community health centres [C] attending a 1 day face-to-face “Community health centres can increase their familiarity with concepts workshop [I] can increase their familiarity with concepts [+ O] and their and their ability to use behaviours a result of a brief inter-disciplinary ability to use behaviours [+ O] as a result of a brief faculty development faculty development intervention”. (p. 707) intervention [+ M] Sandau et al. (2011) Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “Cohort 2 preceptors… At 3–6 months… Results for confidence and workshop [I] had increased confidence, understanding and abilities in pre- comfort in all five roles were significantly improved…” (p. 122) cepting new nurses [+ O] through workshop participation [+ M] Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “… nurses in Cohort 2—orientees reported significantly greater workshop [I] helped nursing orientees to increase their confidence on com- confidence on completion of the first assignment after completing pleting their first assignment [+ O] through supervisors completing training orientation compared with Cohort 1—orientees…” (p. 123) [+ M] Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “… Cohort 2—orientees reported greater confidence in the use of criti- workshop [I] helped nursing orientees to increase their confidence in critical cal thinking on completion of orientation… than did nurses new to thinking [+ O] through supervisors completing training [+ M] the hospital.” (p. 123) 546 C. E. Rees et al. 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “At 1 year post intervention, the proportion of new nurses (125 of 132) workshop [I] helped nursing orientees’ retention within the hospital within retained was significantly greater than in the previous year (82 of a year of commencing their new role [+ O] through supervisors completing 94).” (p. 123) training [+ M] Sandau and Halm Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “However, the quality of some preceptors was described as subpar, (2011) workshop [I] led to nursing orientees experiencing negative orientation [− O] often because of lack of time.” (p. 176) because their preceptors did not have protected supervision time [− M] Nursing preceptors [C] undergoing the workshop [I] had a negative precept- “Mismatched schedules of preceptors and orientees, as a result of 8- ing experience [− O] because of mismatched schedules of preceptors and versus 12-h shifts, rotating shifts, or preceptor vacation time, were orientees [− M] cited as barriers to effective precepting.” (p. 179) Sayani et al. (2017) Midwifery participants [C] who have attended a 2-day mentorship workshop [I] “The reasons for not beginning to work as a mentor were cited as busy did not begin to work as a mentor [− O] because they were occupied by other work schedule, attending other training sessions, and personal com- commitments [− M] mitments.” (p. 516) Taylor et al. (2007) The pharmacist preceptors [C], after participating in the online programme [I], “Many participants experience a change in attitude to their role of experienced positive preceptor–preceptee relationships [+ O] as they changed being a preceptor and this indirectly affected his/her ability with the their attitudes to their role of being a preceptor [+ M] students.” (p. 51) The pharmacist preceptors [C] undergoing the online programme [I] can now “All groups voiced their appreciation for the flexible delivery mode access the training [+ O] as it is flexible in its delivery mode [+ M] of the program which enabled them to access an educational course from their rural location.” (p. 50) The pharmacist preceptors [C] after undergoing the online programme [I] “For many, their prior experiential learning was validated, reinforced experienced confidence growth in their abilities to be an effective precep- and extended and lead to a subsequent increase in confidence in their tor [+ O] as their prior experiential learning was validated, reinforced and abilities to be an effective preceptor.” (p. 51) extended [+ M] NGRN new graduate registered nurse; RN registered nurse; NP nursing preceptor Supervision training in healthcare: a realist synthesis 547 Extended‑duration supervision training interventions Extended-duration supervision training interventions also typically focused on partici- pants developing their supervisory knowledge and skills (content), were delivered face- to-face (mode) and employed multiple approaches such as didactic (e.g. presentation, videos, reading), active (e.g. group discussions, reflective activities) and experiential learning (e.g. group supervision). Indeed, differences between short and extended-dura- tion interventions (other than their longevity) were subtle, including: (1) some short- duration interventions being delivered online, and (2) more extended-duration interven- tions employing experiential pedagogical strategies. Although middle-range theories underpinning extended-duration interventions were sometimes absent or not speci- fied in the outputs (e.g. ‘learning theory’, ‘psychodynamic theory’), various theories were identified. The most commonly identified were experiential learning (Kolb 1984), reflective practice (Schön 1987), and social learning theories (Proctor and Inskipp 2001; Shulman 1991, 1993, 2005). We were able to identify fewer demi-regularities across our wide-ranging CMOCs for extend-duration interventions (Table 5). Firstly, we found five demi-regularities consistent with those already identified above for short-duration interventions but these were some- times expressed in the reverse way (e.g. negative outcomes for extended but positive out- comes for short-duration interventions): Healthcare supervisors [C] undergoing extended-duration supervision training [I] expe- rienced improved supervisory knowledge and practices [+ O] through mixed pedagogi- cal strategies emphasizing active and/or experiential learning [+ M] (Halabi et al. 2012; Myrick et al. 2011; Ögren et al. 2008; Rogers and McDonald 1992; Seo and Engelhard 2014). • Healthcare supervisors [C] undergoing extended-duration supervision training [I] expe- rienced modest outcomes only [− O] through a lack of systematic training involving mixed pedagogical strategies [− M] (Milne and Westerman 2001; Rogers and McDon- ald 1992). • Healthcare supervisors [C] undergoing extended-duration supervision training [I] experienced improved supervisory knowledge and practices [+ O] through supervisor engagement [+ M] (Tebes et al. 2011). Healthcare supervisors [C] undergoing extended-duration supervision training [I] expe- rienced poor supervisor engagement in training [− O] through insufficient protected time [− M] (Ögren et al. 2008). • While healthcare supervisors [C] undergoing extended-duration supervision training [I] experienced improved supervisory satisfaction, knowledge, practices and/or atti- tudes [+ O] through positive social relationships [+ M] (Myrick et al. 2011; Ögren et al. 2008; Sundin et al. 2008), they experienced modest outcomes only [− O] through chal- lenging social relationships [− M] (Milne and Westerman 2001; Ögren et al. 2008). We identified only one additional demi-regularity for the extended-duration interven- tions, not prominent for short-duration interventions: While healthcare supervisors [C] undergoing extended-duration supervision training [I] experienced improved supervisory engagement, knowledge and/or practices [+ O] through positive facilitator styles [+ M] (Myrick et al. 2011; Ögren et al. 2008; Sundin et  al. 2008; Sevenhuysen et  al. 2013), they experienced modest outcomes only [− O] through negative facilitator styles [− M] (Sundin et al. 2008). 1 3 548 C. E. Rees et al. Fig. 3 Modified program theory—short duration intervention Based on these demi-regularities we developed a MPT for extended-duration interven- tions (Fig. 4). Discussion This synthesis set out to address the research questions: to what extent do supervision train- ing interventions work (or not), for whom and in what circumstances, and why? Through our realist synthesis of 29 research outputs, we were able to develop two novel program theories, grounded in that evidence, about the positive and negative outcomes of short and extended-duration supervision training interventions, the mechanisms underpinning those outcomes and the extent to which those relationships were context-dependent, thereby developing existing knowledge on supervision training interventions. Summary of key findings The developed program theories demonstrate that both short and extended-duration super- vision training interventions have a multiplicity of positive supervisor outcomes including improved satisfaction, knowledge, skills, and engagement through a combination of mech- anisms including mixed pedagogical approaches involving active and/or experiential learn- ing, plus privileging social relationships (e.g. teacher–learner, peer–peer). Furthermore, both modified program theories illustrate that short and extended-duration supervision training interventions can lead to poor supervisor engagement in training when insufficient protected time exists for supervisor learning. Additionally, while most of the literature reviewed originated from health professions rather than human services contexts, we did not find that variations in disciplinary or organisational contexts were especially relevant to 1 3 Supervision training in healthcare: a realist synthesis 549 1 3 Table 5 CMOCs for extended-duration interventions References CMOC Illustrative quote (page number) Halabi et al. (2012) Female registered nurses with more than 5 years’ clinical experience [C] “The participants described how the pedagogical strategies improved undergoing a metropolitan university based part-time preceptor training their teaching in the practice area” (p. 139) program over 6 months (1 week every 3 months) [I] had improved their clinical teaching and capacity to guide students to integrate theory and practice [+ O] through the learning environment facilitating experiential learning pedagogies [+ M] Female registered nurses [C] undergoing a part-time preceptor train- “In addition, most participants noted that they became better prepared to ing program over 6 months [I] had improved their ability to manage manage challenging learning situations while attending the program” challenging learning situations [+ O] through the learning environment (p. 140) facilitating experiential learning pedagogies [+ M] Female registered nurses [C] undergoing a part-time preceptor training “Participants reported… improved communication skills with col- program over 6 months [I] had improved their communication skills leagues, students, and hospital staff” (p. 141) [+ O] through the learning environment facilitating experiential learning pedagogies [+ M] Female registered nurses [C] undergoing a part-time preceptor training “The participants stated that learning became easier and more fun when program over 6 months [I] had improved student supervisees’ active their students could share their ideas in a group discussion.” (p. 140) involvement in group supervision sessions [+ O] through preceptors’ applying experiential learning pedagogies into group supervision [+ M] Milne and Westerman The supervisor [C] after undergoing the 8-month 1-h weekly consultancy “Frisch (1989) used a carefully designed 40 h module to develop super- (2001) and feedback [I] only received a modest outcome from the supervision vision skills… This included handouts and audio–visual aids, in con- activities [− O] because the consultancy was not sufficiently systematic junction with diverse teaching methods… Comparison with these two [− M] examples indicates, therefore, that the present study may have had its relatively limited impact because the consultancy was not sufficiently systematic.” (p. 454) The supervisor [C] after undergoing the 8-month 1-h weekly consultancy “… experiential learning methods are inherently challenging… effortful, and feedback [I] only received a modest outcome from the supervision and carry with them a considerable degree of uncertainty as to the activities [− O] because the supervisees prefer amicable supervisor– outcome… This creates the conditions for the supervisees to counter- supervisee relationships and exert a certain degree of influence over the control or collude with the supervisor, as both parties would be more supervisor–supervisee relationship [− M] comfortable with the more supportive and non-threatening methods of learning…” (p. 454) 550 C. E. Rees et al. 1 3 Table 5 (continued) References CMOC Illustrative quote (page number) The supervisor [C] after undergoing the 8-month 1-h weekly consultancy “… supervisees… experienced considerable stress in trying to imple- and feedback [I] only received a modest outcome from the supervision ment the PSI [psychosocial intervention] methods… the supervisor activities [− O] because the supervisor did not want to put too much often felt overwhelmed by the welter of stressors brought into supervi- pressure on already stressed supervisees [− M] sion sessions… a collusive relationship was possibly shaped by nega- tive reinforcement on both sides… an important threat to evidence- based supervision” (p. 455) Myrick et al. (2011) The nursing preceptors [C] undergoing the e-learning technology [I] “The social presence was ensured through the provision of a full time were engaged to reflect on information [+ O1] and acquired precepting facilitator who engaged the participants in both synchronous and asyn- knowledge [+ O2] because a full-time facilitator interacted with them chronous discussion and interactive sessions throughout the trajectory and ensured that they engaged in dialogue that was current, relevant, of the program…” (p. 265) supportive and connected [+ M1] The nursing preceptors with lower computer literacy [C] undergoing the “The Virtual Space. [I]tself was found by the preceptors to be challeng- e-learning technology [I] acquired technological skills and ability [+ O] ing and engaging while at the same time it was also found to provide due to the opportunity to enhance their individual skill in the use of them with an opportunity to enhance their individual skill in the use of technology [+ M] technology.” (p. 265) The nursing preceptors [C] who received the e-learning technology [I] “In the planning of this online preceptorship support program, an experienced interaction, learning and growth [+ O] due to the careful instructional designer with a background in educational theory was planning and integration of instructional strategies orchestrated by a consulted so that the appropriate learning tools could be adopted to competent instructional designer [+ M] facilitate an effective learning experience of the preceptors.” (p. 266) Ögren et al. (2008) When supervisors [C] undergoing the 2-year training program [I] were “… supervisors believed that it was important that they assumed a slow at understanding, the facilitators could help supervisors find their humble attitude when they did not understand something that was own pace of understanding [+ O] and alternative ways of seeing [+ O] expressed during the supervision. It was considered essential to wait when the facilitators were humble and patient [+ M] for the supervisees and to let each of them find their own pace of understanding what was happening in the interplay.” (p. 12) The supervisors [C] undergoing the 2-year training program [I] had posi- “The supervisees generally experienced that the program supervisors tive experiences of finding their paths to solutions [+ O] as the facilita- had actively sought to create space for the supervisees to reflect and tors gave them space to reflect and think [+ M] ponder. Supervisees were given the opportunity to find their own paths to solutions” (p. 13) Supervision training in healthcare: a realist synthesis 551 1 3 Table 5 (continued) References CMOC Illustrative quote (page number) The supervisors [C] who underwent the 2-year training program [I] expe- “Something that contributed to security and quality in supervision was rienced security and quality in supervision [+ O] because the facilitator that the supervisor was direct and expressed him or herself clearly was direct and expressed themself clearly without being offensive [+ M] without being offensive” (p. 14) The supervisors [C] who underwent the 2-year training program [I] “This attitude [of openness and curiosity] was experienced as having experienced an attitude of openness and curiosity when sharing their contributed to an increased confidence… To feel free to talk about problems [+ O] through increased confidence [+ M] and feeling free to one’s work, to be able to associate with colleagues without being talk about their work without fear of judgement [+ M] scared of being “right or wrong,” was emphasized as being important and a worthwhile aim.” (p. 13) The supervisors [C] undergoing the 2-year training program [I] could feel “An extremely passive style could, however, create insecurity amongst insecurity [− O] if the facilitators were extremely passive in style [− M] the supervisees.” (p. 14) Supervisors [C] undergoing the 2-year group training program [I] “Each group member is given the opportunity to follow the development improved their understanding that one situation could be managed in of the other prospective supervisors and their respective therapists various ways [+ O] through listening and thinking about lots of perspec- and clients over time. It becomes clear that one can manage similar tives on situations [+ M] situations in various ways depending on the particular circumstances.” (p. 15) “Many supervisees reported that the interplay with the group members, The supervisors [C] in the 2-year training program [I] were led to new ideas and associations [+ O] through the interplay with other group which included giving attention to their presentations and receiv- members [+ M] ing their views on their work, gave them new ideas and associations related to their own work” (p. 17) The supervisors [C] who underwent the 2-year training program [I] were “Competition for time and a perceived lack of space contributed periodi- struggling to find their place in the group [− O] as they were aware that cally to difficulties for supervisees in finding their place in the group” each member’s time was limited [− M] (p. 18) The supervisors [C] undergoing the 2-year training program [I] success- “Thus, this study provided support for the idea that supervision of pro- fully shifted their perspective from being a psychotherapist to a supervi- spective supervisees combined with theoretical seminars, in a unique sor [+ O] through the training program combining theoretical seminars way, contributes to this type of shift in perspective among supervi- and group supervision [+ M] sees” (p. 19) 552 C. E. Rees et al. 1 3 Table 5 (continued) References CMOC Illustrative quote (page number) Paulson and Casile (2014) Rural mental health supervisors [C] undergoing a 1-day supervision train- “Overall, the group began without high levels of burnout and isolation, ing plus 6 monthly peer group supervision sessions [I] had decreased but still grew positively throughout the 6 months… the results suggest emotional exhaustion [+ O] and decreased depersonalisation [+ O] that the supervisors may have become more energised, connected, and because they became more energized, connected and confident through- confident throughout the peer supervision sessions” (p. 214) out the peer group supervision sessions [+ M] Rogers and McDonald Social work field instructors [C] undergoing a 10-week, 20-h program “This type of learning assignment, which forced them to actually reflect, (1992) [I] had improved their ability to discriminate between truth and falsity consider, and articulate their inferences, might account for the increase [+ O] because of the pedagogical techniques employed facilitating in ability” (p. 174) supervisor reflection on inferences [+ M] Social work field instructors [C] undergoing a 10-week program [I] had “The intent was to provide a learning environment and learning experi- improved critical thinking [+ O] through the learning environment ences that would facilitate and encourage critically reflective field facilitating critical reflection [+ M] instruction methods and practices” (p. 174) Social work field instructors [C] undergoing a 10-week program [I] “There was little emphasis in the course in terms of content, exercise, or showed no improvements in their abilities to determine if conclusions assignments on deduction, or on interpretation which may explain why follow from information [− O] and no improvements in abilities to there was no significant change in those areas” (p. 174) weigh evidence and decide whether conclusions are warranted [− O] because the course materials did not emphasise deduction or interpreta- tion aspects of critical thinking [− M] Seo and Engelhard (2014) Physical therapy clinical instructors [C] engaging in an online continu- “The online module evoked motivation, critical thinking, self-directed ing education module [I] experienced perceptions of improved student learning, and self-reflection and that the participants perceived an mentoring quality [+ O] because of evoked motivation, critical thinking, improvement in the quality of student mentoring.” (p. 49) self-directed learning and self-reflection [+ M] Sevenhuysen et al. (2013) Physiotherapy clinical educators [C] undergoing four 2-h workshops to “… this level of engagement was achieved by responding to the con- design and develop a peer-assisted learning (PAL) model of clini- tinual critical review of stakeholder feedback and adjusting the content cal education for paired undergraduate physiotherapy students [I] of the workshops, and the model itself, based on the feedback. It was experienced improved engagement with the peer learning model [+ O] also achieved by allowing “space” for participants to raise concerns because facilitators adjusted the content of workshops, and model, and discuss potential solutions for these concerns” (p. 42) based on feedback [+ M] and provided space during workshops to raise stakeholder concerns and develop solutions for concerns [+ M] Supervision training in healthcare: a realist synthesis 553 1 3 Table 5 (continued) References CMOC Illustrative quote (page number) Physiotherapy clinical educators [C] undergoing four 2-h workshops [I] “Peer assisted learning (educator to educator) was deliberately employed experienced improved engagement with the workshops [+ O] because as a strategy for engaging participants in workshops, as clinical of peer learning strategies used during the workshops as a strategy for educators were encouraged to learn from one another’s experience and engaging stakeholders [+ M] ideas” (p. 36) Sundin et al. (2008) Accredited psychotherapists (who had conducted > 125 psychotherapy “… a supervisor style that was perceived as more decisive (consulta- sessions and practiced for > 3 years post-authorisation) [C] undergoing tive, directive, active, structured) at 6 months contributed to perceived a 2-year part-time psychotherapy training program [I] gained knowledge attainment of psychotherapeutic knowledge and skills at the 18-moth and skills [+ O] through facilitators using more decisive styles [+ M]; measurement” (p. 389). and facilitators adopting authoritative approaches in the early to middle phases of the program [+ M] Accredited psychotherapists [C] undergoing a 2-year part-time psycho- “… the negative association between self-ratings of a theoretical style therapy training program [I] did not help trainees attain knowledge and and knowledge attainment could be taken to suggest that the trainees skills [− O] if their supervisor prioritised a theoretical style [− M] experience the task to integrate supervisory practice with theoretical considerations to be extremely challenging and frustrating” (p. 392) Accredited psychotherapists [C] undergoing a 2-year part-time psycho- “The results suggested that the relationship among trainees was a sub- therapy training program [I] enhanced knowledge and skills [+ O] stantial predictor of attained knowledge” (p. 391) because of the positive relationships in a small group [+ M] Tebes et al. (2011) Licensed social workers with 16 years’ clinical experience and 8 years’ “… training in interactional supervision was associated with significant supervision experience [C] undergoing a 5-day interactional supervision increases in supervisors’ perceived ability to manage supervisory relationships, manage supervisee job performance, and promote the training program over 7 months [I] experienced perceived increases in their competency [+ O] through participating in the training program professional development of their supervisees” (pp. 195–196) and applying learnt skills in their supervision practice [+ M] Licensed social workers [C] undergoing a 5-day training program over “…managing supervisory relationships significantly predicts increases 7 months [I] experienced decreased supervisory stress [+ O] through in supervisor stress management” (p. 195) understanding and applying approaches to managing the supervisory relationship [+ M] Licensed social workers [C] undergoing a 5-day training program over “… increases in supervisor competencies are associated with increased 7 months [I] experienced increased satisfaction with their supervisory supervisor satisfaction… managing supervisory relationships and role [+ O] through understanding and applying approaches to managing managing job performance significantly predict increases in supervisor the supervisory relationship and a decrease in supervisory stress [+ M] satisfaction” (p. 195) 554 C. E. Rees et al. our program theories for short or extended-duration interventions. However, when compar- ing the mechanisms underpinning short and extended-duration training interventions, we found that supervisor characteristics (i.e. confidence, knowledge, skills and attitudes) were key mechanisms triggering positive outcomes for short-duration interventions, whereas facilitator characteristics were key mechanisms triggering either positive or negative out- comes for extended-duration interventions. In summary, our findings are novel in two key ways: (1) that short and extended- duration interventions have numerous positive outcomes through mixed pedagogical approaches, social learning, and protected time for supervisors; and (2) that interventions of different durations may work in slightly different ways, with the success of short inter - ventions relying on supervisor characteristics, and extended-duration interventions instead relying on facilitator characteristics. Comparison with existing literature That mixed pedagogies involving active and/or experiential learning were important for the success of supervision training interventions is consistent with educational theories e.g. reflective practice (Schön 1987), experiential learning (Kolb 1984), plus our IPT based on three non-realist reviews of supervision training (Milne et  al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Furthermore, that social relationships were also impor- tant for positive supervision training program outcomes in our modified program theories is also consistent with social learning theories (Shulman 1991, 1993, 2005; Proctor and Inskipp 2001). Finally, that negative outcomes occurred when supervisors were provided with insufficient protected time for learning, is consistent with literature emphasising the tensions between training and service delivery (Sholl et al. 2017). However, the findings of our realist synthesis not only extend our IPT but also add considerable new knowledge to the supervision training literature (Milne et al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Fig. 4 Modified program theory—extended duration intervention 1 3 Supervision training in healthcare: a realist synthesis 555 Firstly, our findings illustrate a wider range of outcomes (including negative outcomes) than has been previously identified in the supervision training literature including our IPT (Milne et al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Furthermore, aligned with our IPT based on previous non-realist reviews (Milne et  al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011), we expected extended-duration interventions to have enhanced pos- itive outcomes compared with short interventions, but we did not find this to be the case based on our realist synthesis of 29 outputs. It is worth noting that our synthesis included nineteen short and ten extended-duration studies from which to draw our conclusions, con- sistent with previous literature suggesting that short-duration supervision training interven- tions were more commonly delivered (Gonsalvez and Milne 2010). We did not identify additional positive outcomes for extended-duration interventions, plus we identified fewer demi-regularities across our identified CMOCs for extended-duration interventions. While this may reflect the fewer outputs reviewed in our study employing extended durations, our findings may reflect a genuine lack of added benefit from extending the duration of supervision training interventions. Indeed, healthcare workers may only require short inter- ventions in order to realize key positive outcomes from training (as long as those short interventions include mixed pedagogies, social learning, protected time, and supervisor characteristics like confidence). Secondly, our findings provide novel insights into the causal pathways for the multi- plicity of ways in which both short and extended-duration supervision training interven- tions work (or not). Indeed, our realist lens has enabled us to identify the multiplicity of mechanisms triggered within supervision training interventions, leading to various positive supervisor outcomes. While interventions of any duration seemed to work through mixed pedagogies, social relationships and protected time (consistent with previous research and educational theories as described above), short interventions seemed to work through supervisor characteristics, whereas extended-duration interventions seemed to work (or not) based on facilitator characteristics. That learner characteristics seemed central in the face of short interventions mirrors previous research flagging the importance of supervi- sors’ personal qualities and skills as key contributors to supervision effectiveness (Wearne et  al. 2012; Gibson et al. 2018), plus learning theories associated with the short-duration interventions, which were exclusively individualist and constructivist in nature such as adult learning theories (Knowles 1990), experiential learning (Kolb 1984) and the nov- ice-to-expert model (Benner 1982). That extended-duration interventions seemed depend- ent on facilitator characteristics, probably relates to the increased importance of facilita- tor–supervisor relationships in the face of enduring associations (sometimes several years long). This also mirrors our finding that extended-duration interventions were associated with middle-range social educational theories. Methodological strengths and challenges Our synthesis was strengthened through the use of a large multidisciplinary team and a rig- orous process aligned with the RAMESES guidelines (Wong et al. 2013, 2017). However, we acknowledge several potential challenges concerning this synthesis. First, although we worked closely with a medical librarian and piloted our search terms, due to the volu- minous nature of the supervision training literature, plus the extensive range of contexts included in our searches, we recognize that we inevitably omitted terms associated with supervision and/or training (e.g. coaching, facilitation etc.) (Lee et  al. 2019). Therefore, we may not have identified all potentially key studies. Second, although our search strategy 1 3 556 C. E. Rees et al. and inclusion criteria did include human services, this literature was either absent or excluded because of its poor quality and/or low realist relevance, meaning that our findings speak to health rather than human services contexts. Third, while we decided to include only peer-reviewed outputs due to the vast supervision training literature, we acknowl- edge that we may have excluded potentially important non-peer-reviewed grey literature, which may have been beneficial in the development of our program theories, and could have accounted for human services contexts. Fourth, none of the outputs included in our synthesis employed realist evaluation methods and as such, we struggled to tease out how context influenced the program theories. Fifth, like others who have identified a lack of evidence pertaining to the outcomes of supervision training on supervisees (e.g. students) and healthcare consumers (Gibson et  al. 2018), the outcomes of studies included in our synthesis are somewhat limited to supervisor outcomes (and often based on self-report). Finally, the papers included in our realist synthesis often lacked explicit articulation of middle-range educational theories on which to base the development and refinement of our program theory. Furthermore, when theories were drawn on they were typically older indi- vidualist theories, rather than more sophisticated contemporary social educational theories. Implications for further research Our study findings and our methodological challenges have a number of implications for further research. Firstly, given that our realist synthesis focuses primarily on health con- texts, further literature reviews are now needed to explore supervision training in human services, perhaps employing different types of review (e.g. narrative review) to describe the types and outcomes of supervision training interventions for human services workers. Secondly, given that our realist synthesis has presented somewhat contradictory and unex- pected findings about intervention duration, further research is now needed to explore more fully the similarities and differences between short and extended-duration supervision training interventions in terms of how they work (or do not work), for whom and under what circumstances, plus drawing on more contemporary social educational theories. The next stage of our supervision training study will employ realist evaluation (Wong et  al. 2012), in order to explore the outcomes of short (i.e. half-day workshops) and extended- duration supervision training interventions for health and human services workers (i.e. half-day workshops plus 3-month longitudinal audio diaries), their underlying mechanisms and associated contextual nuances. Indeed, through employing realist evaluation we hope to better tease out how contextual variations influence mechanisms generating outcomes. Thirdly, similar to others reporting limitations in how the effectiveness of supervision training has traditionally been measured (Milne et al. 2011), further research is now needed that extends the ‘measurement’ of outcomes beyond supervisor outcomes to include out- comes for supervisees, and healthcare consumers. Indeed, realist evaluation could help to flesh out the multiplicity of outcomes for supervisors, supervisees and healthcare consum- ers, as well as identifying the multiple causal pathways. Implications for educational practice Investment in supervision training has been proposed as having greater positive impact than resourcing supervision alone (Hill et  al. 2014). In the quest to develop healthcare workers’ supervisory practices, we have found that supervisor training interventions of any duration can work to enhance supervisors’ confidence, knowledge, skills, and engagement 1 3 Supervision training in healthcare: a realist synthesis 557 through mixed pedagogical approaches involving active and/or experiential learning, privileging social relationships, and protected time. Supervision training that extends over longer periods of time showed no evidence of additional benefits in our realist synthesis. Our review therefore implies that only a modest investment may be required to produce significant outcomes for supervisory practices. These findings are important for resource- sensitive healthcare systems that fund the supervision training of healthcare workers. If offering short-term duration interventions, supervisor characteristics become important mechanisms triggering positive outcomes, whereas facilitator characteristics become cen- tral mechanisms triggering outcomes for extended-duration interventions. Therefore, we encourage healthcare educators involved in the design and facilitation of supervision train- ing interventions to pay close attention to the key mechanisms highlighted in this realist synthesis in order to maximise the positive outcomes of supervision training interventions for supervisors. Finally, from an organizational perspective, supervision training programs need to be situated within organizational workplace cultures that enable supervisors to apply their new-found supervisory knowledge and skills to supervisory practices. Ulti- mately, healthcare organisations need to operate as positive learning organisations in order to maximise supervisory outcomes from training programs. Acknowledgements We would like to thank Anne Young, Medicine, Nursing and Health Sciences Librar- ian from the Hargrave-Andrew Library, Monash University, for her invaluable assistance in the develop- ment of our search strategies and the conduct of those strategies. We would also like to thank Kat Orgallo, Graphic Designer, Teaching Resources Support Unit (TRSU), Faculty of Medicine, Nursing and Health Sci- ences, Monash University, for her help in designing our initial and modified program theory figures. Author’s contributions All authors except EH contributed to the development of the protocol. All authors except EH contributed to clarifying the scope of the synthesis. SLL led the conduct of the searches with feedback from all other authors except EH. All authors except EH participated in the initial study selec- tion based on titles and abstracts involving the relevance of outputs. All authors participated in assessing the rigour and realist relevance of full-text outputs. All authors except VE and BW extracted data from the included studies (with the bulk of this data extraction being conducted by EH). CER led the synthesis stage with input from SLL, EH and CP, and feedback from remaining authors. CER led the write-up of the paper, with input from SLL (methods) and CP (discussion), and feedback and editing from all remaining authors. All authors approve the final version of the paper. CER is principal investigator and acts as guarantor for the paper. 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Affiliations 1 1 1 1,2 Charlotte E. Rees  · Sarah L. Lee  · Eve Huang  · Charlotte Denniston  · 1 3 4 4 5 Vicki Edouard  · Kirsty Pope  · Keith Sutton  · Susan Waller  · Bernadette Ward  · Claire Palermo Monash Centre for Scholarship in Health Education (MCSHE), Monash University, 27 Rainforest Walk (Building 15), Clayton Campus, Clayton, VIC 3800, Australia Department of Medical Education, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, Australia Monash Rural Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Warragul, VIC, Australia Monash Rural Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Bendigo, VIC, Australia 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Advances in Health Sciences Education Springer Journals

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Abstract

Supervision matters: it serves educational, supportive and management functions. Despite a plethora of evidence on the effectiveness of supervision, scant evidence for the impact of supervision training exists. While three previous literature reviews have begun to examine the effectiveness of supervision training, they fail to explore the extent to which supervi- sion training works, for whom, and why. We adopted a realist approach to answer the ques- tion: to what extent do supervision training interventions work (or not), for whom and in what circumstances, and why? We conducted a team-based realist synthesis of the super- vision training literature focusing on Pawson’s five stages: (1) clarifying the scope; (2) determining the search strategy; (3) study selection; (4) data extraction; and (5) data syn- thesis. We extracted contexts (C), mechanisms (M) and outcomes (O) and CMO configura- tions from 29 outputs including short (n = 19) and extended-duration (n = 10) supervision training interventions. Irrespective of duration, interventions including mixed pedagogies involving active and/or experiential learning, social learning and protected time served as mechanisms triggering multiple positive supervisor outcomes. Short-duration interven- tions also led to positive outcomes through mechanisms such as supervisor characteristics, whereas facilitator characteristics was a key mechanism triggering positive and negative outcomes for extended-duration interventions. Disciplinary and organisational contexts were not especially influential. While our realist synthesis builds on previous non-realist literature reviews, our findings extend previous work considerably. Our realist synthesis presents a broader array of outcomes and mechanisms than have been previously identified, and provides novel insights into the causal pathways in which short and extended-duration supervision training interventions produce their effects. Future realist evaluation should explore further any differences between short and extended-duration interventions. Educa- tors are encouraged to prioritize mixed pedagogies, social learning and protected time to maximize the positive supervisor outcomes from training. Keywords Supervision · Training · Health · Realist synthesis Charlotte E. Rees and Sarah L. Lee are joint lead authors. * Charlotte E. Rees charlotte.rees@monash.edu Extended author information available on the last page of the article 1 3 Vol.:(0123456789) 524 C. E. Rees et al. Introduction Supervision matters in health and human services. While definitions of supervision vary across the literature (Martin et al. 2017), Proctor’s popular model outlines three purposes of supervision: facilitating consistent and quality practice in supervisees (managerial func- tion), helping the development of supervisees’ knowledge, skills, attitudes and practices (educational function), plus providing supervisees with support and validation (restorative function) (Proctor 1987; Brunero and Stein-Parbury 2008; Dilworth et al. 2013; Gonsalvez and Milne 2010). See Box 1 for varying examples of definitions for supervision. An effec- tive supervisor skilfully provides feedback, teaches, fosters collaborative learning, under- stands the expectation of their supervisees and is organized (Gibson et  al. 2018). While supervision training is thought to enhance supervision effectiveness (Martin et  al. 2014; Fitzpatrick et  al. 2012; Dilworth et  al. 2013; Chu et  al. 2016), supervisors in health and human services consistently lack such training (MacDonald 2002; Spence et  al. 2001; Hoge et  al. 2011; Butterworth et  al. 2008). Despite a plethora of evidence on the qual- ity and effectiveness of supervision over the last 20  years (Spence et  al. 2001; Hill et  al. 2014; Newton et  al. 2016), scant evidence evaluating the impact of supervision training exists. Only three reviews exist in the literature focusing on supervision training (Milne et al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). While these reviews begin to offer insights into the effectiveness of supervision training, they largely focus on the positive outcomes of supervision training without explicitly discussing the complexities around how training interventions influence the quality or effectiveness of supervision. To address this gap in the supervision training literature, we conducted a realist synthesis to explore the extent to which supervision training works (or does not work), for whom and under what circumstances, how and why. Diversity and complexity of supervision training interventions While many argue for the importance of training to enhance supervision effectiveness (Kilminster and Jolly 2000), supervisors often carry out their supervision roles without any specific training (Hoge et  al. 2011). For supervisors who do experience supervision Box 1 Example definitions of supervision “Clinical supervision is a process of professional support and learning in which nurses are assisted in developing their practice through regular discussion time with experienced and knowledgeable colleagues…” (Brunero and Stein-Parbury 2008, p. 87) “Supervision is any activity where more experienced health professionals provide less experienced health professionals with opportunities that enable these health professionals to achieve learning, to receive support, and to improve the quality and safety of their practice” (Fitzpatrick et al. 2012, p. 462) “Supervision is a forum where supervisees review and reflect on their work in order to do better. Practitioners bring their actual work-practice to another person (individual supervision), or to a group (small group or team supervision), and with their help review what happened in their prac- tice in order to learn from that experience” (Caroll 2007, p. 36) “The formal provision, by approved supervisors, of a relationship-based education and training that is work-focused and which manages, supports, develops and evaluates the work of colleagues…” (Milne 2007, p. 439) “The term clinical supervision is defined as a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, and is acknowledged to be a life-long process…” (Martin et al. 2014, p. 201) 1 3 Supervision training in healthcare: a realist synthesis 525 training, they can experience a wide diversity in training with respect to content, mode, pedagogical strategies and duration. Supervision training content often focuses on the development of supervisor knowledge (e.g. definitions, models, methods, responsibilities, legal/ethical aspects) (Kilminster and Jolly 2000; Spence et al. 2001; Newton et al. 2016), and/or skills (teaching, assessment, feedback, counselling, leadership, interpersonal) (Kilminster and Jolly 2000; Hill et  al. 2014; McKellar and Graham 2017). Supervision training modes include face-to-face, online or blended approaches. Pedagogical strategies also vary including didactic (e.g. presentations, videotaped demonstrations), active (e.g. small group discussions) and/or experiential learning (e.g. role-play, feedback) (Spence et  al. 2001; Hoge et  al. 2011; Pollock et  al. 2017). The duration of supervision training ranges from one-off, short-term interventions (such as a 2-day workshop) to extended- duration interventions over many months that are punctuated by mini-interventions such as monthly supervision sessions (Spence et al. 2001). Although competency frameworks for supervision have been developed to guide supervision training (Health Workforce Australia 2014), some scholars argue that a lack of specificity still exists in terms of what and how supervision training should be conducted (Reiser and Milne 2014; Alfonsson et al. 2018). Furthermore, supervision training interventions have been criticised for lacking theoretical and evidence-based foundations (Kilminster and Jolly 2000). Therefore, we designed this realist synthesis to address these criticisms and gaps in the current literature. A realist approach to supervision training Given the diversity and complexity of supervision training interventions, a realist synthe- sis was used to better understand how and why supervision training interventions produce their effects. A realist approach is theory-driven, so facilitates the development and modi- fication of program theories accounting for how and why interventions work (or do not work) and for whom and when (Wong et al. 2012, 2016). This approach is underpinned by scientific realism, which asserts that it is not interventions that create change; rather, it is people who create change (Pawson and Tilley 1997). Interventions are thought to lead to outcomes through the operation of mechanisms, that is, the resources proffered by an inter - vention and the ways in which this influences participants’ reasoning (Dalkin et al. 2015). Furthermore, there is an appreciation that this complex relationship is context-dependent (Sholl et al. 2017; Ajjawi et al. 2018). Outcomes of any intervention can be affected by the range of conditions within any given setting, which are often sociocultural (Jolly and Jolly 2014). The basic premise is: what works for one person might not work for another; and what works in one circumstance might fail to work in another (Wong et al. 2016). While the context–mechanism–outcome (CMO) relationship is not necessarily straightforward or linear, contextual aspects are thought to trigger particular mechanisms in response to an intervention leading to particular outcomes (Jolly and Jolly 2014). See Box 2 for a glossary of key realist terms. Developing an initial program theory from non‑realist supervision training reviews Three supervision training reviews, one narrative and two systematic, have so far been pub- lished in the literature (Milne et  al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). While none of these employed realist approaches, nor did they include middle-range theory (MRT) specific to education apart from mentioning Kolb’s (1984) experiential learning (Milne et  al. 2011), we applied realist logic in our reading of these reviews to develop 1 3 526 C. E. Rees et al. Box 2 Glossary of realist terms Contexts can be described as: “the conditions that an intervention operates in (often but not exclusively sociocultural)” (Taylor et al. 2007, p. 28). Context can refer to individuals participating in programs, stakeholder interrelationships, institutional arrangements in which programs sit and/or wider cultural, economic and/or societal settings for programs (Pawson 2018). Mechanisms can be described as: “underlying entities, processes or structures which operate in particu- lar contexts to generate outcomes of interest” (Astbury and Leeuw 2010, p. 368). Mechanisms are typically hidden, sensitive to contextual variations and generative of outcomes (Astbury and Leeuw 2010). Outcomes can be described as the desired products of a program and/or the program’s observed prod- ucts (Yardley et al. 2015; Jolly and Jolly 2014). Context–mechanism–outcome configurations (CMOCs) can be described as heuristics employed “by some realists during analysis to identify the causal links between context, mechanism and outcomes” (Marchal et al. 2018, p. 83). Demi-regularities can be described as: “prominent recurrent patterns of contexts and outcomes… in the data” (Wong et al. 2013, p. 9). Program Theory can be described as: “a plausible and sensible model of how a program is supposed to work” (Bickman 1987, p. 5). A program theory therefore is an explanatory account of how a program works, under what circumstances and for whom (Astbury and Leeuw 2010). Such a theory-driven approach should include both the development of, and testing and refinement of, program theory (Astbury and Leeuw 2010). Middle-range theory (MRT) can be described as theory situated: “between the minor but necessary working hypothesis… and the all-inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behavior, social organization and social change” (Merton 1968, p. 83). MRT can be considered formal theory providing a bridge to existing knowledge about a topic (Marchal et al. 2018). an initial program theory (IPT: Fig.  1). We developed this IPT based on our identifica- tion of contexts, mechanisms, outcomes and context–mechanism–outcome configurations (CMOCs) for the supervision training interventions across the three papers. Firstly, studies included in these three reviews had several different contexts including health and human services (e.g. psychology, mental health, allied health), plus commercial contexts such Fig. 1 Initial program theory 1 3 Supervision training in healthcare: a realist synthesis 527 as sales and insurance (Milne et  al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Secondly, the supervision training interventions outlined within these three reviews were complex and diverse in terms of the: (a) content such as knowledge, skills and attitudes; (b) mode of delivery including face-to-face and online learning; (c) pedagogical strategies employed including theoretical and experiential learning; and (d) duration of the interven- tions including short (e.g. half-day) and extended durations (e.g. year) (Milne et al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Third, a variety of (mostly) positive outcomes were identified within the three reviews and related to supervisors (e.g. improved satisfac- tion, confidence, knowledge, skills) and supervisees (e.g. improved satisfaction and mental health). Fourth, we were also able to identify some mechanisms in the reviews to explain why interventions produced their effects e.g. supervision training interventions having an appropriate balance between didactic and experiential learning methods and extended durations enhancing engagement. Finally, we were able to identify two distinct CMOCs in two of the reviews: Within mental health supervision [C] clinical supervision training [I] leads to supervi- sor and supervisee development [O] through having a blend of pedagogic methods such as feedback, educational role-play and modelling [M] (Milne et al. 2011). • Within the workplace [C], supervision training [I] leads to improved supervisor knowl- edge and behaviour, plus enhanced supervisee mental health [O] through improved knowledge and behavioural modification [M] (Tsutsumi 2011). Study aim and research questions Although we have been able to identify contexts, mechanisms and outcomes and two CMOCs for supervision training interventions from previous reviews using realist logic, and develop an IPT, this current realist synthesis aimed to extend current literature reviews to develop a modified program theory (MPT). It aimed to review the published supervision training literature within health and human services to answer the novel research question: To what extent do supervision training interventions work (or not), for whom and in what circumstances, and why? Methods The review protocol registered on PROSPERO (CRD42018094186) and published (Lee et al. 2019) was underpinned by Pawson’s five stages of realist review: (1) clarifying scope; (2) searching for evidence; (3) study selection; (4) data extraction; and (5) data synthesis (Pawson et al. 2005). Although presented in a linear fashion, stages were conducted itera- tively with some overlap. The review methods and findings follow the RAMESES publica- tion standards for realist syntheses (Wong et al. 2013). Clarifying the scope A matrix identifying existing primary literature/empirical studies, literature reviews, search terms and their synonyms was created, generating numerous search terms. With the help of a medical librarian (see acknowledgements), pilot searches were conducted using several databases to test search terms (those identified as keywords in other 1 3 528 C. E. Rees et al. published supervision training outputs, plus synonyms familiar to our multidiscipli- nary team), Boolean operators and proximity searching. Note that our original scope for this realist synthesis was broad including health (e.g. medicine, nursing, allied health etc.) and human services (e.g. housing, disability, children services, youth and family services, alcohol and drug services, out of home care etc.), consistent with our fund- ing (Victorian Department of Health and Human Services). Furthermore, our scope was also broad in terms of interventions (e.g. workshops, online education, lectures), professions (e.g. nursing, physiotherapy, pharmacology, mental health), contexts (e.g. hospitals, universities, training centers, community services) and levels of learner (e.g. undergraduate students, postgraduate trainees, peers and colleagues). Searching for empirical evidence A final and comprehensive search of the literature was conducted in May 2018 by SLL, with input from the medical librarian and co-authors. Note that none of these final searches were limited by date. Key search terms and phrases included supervisor terms (e.g. supervisor, practice educator, clinical educator, preceptor) and training terms only (e.g. education, professional development, train-the-trainer). Given the breadth of our search, we did not include search terms relating to interventions, professions, contexts or levels of learner, as advised by our medical librarian. For a full list of search terms see the protocol (Lee et  al. 2019). Key terms were combined with proximity search- ing, Boolean operators, truncations and asterisks. Furthermore, searches were adapted to meet the operative requirements of each database including: Educational Resources Information Center (ERIC, ProQuest); Australian Public Affairs Information Service (APAIS, Informit); Social Services Abstracts (ProQuest); Scopus; PsycINFO (Ovid); MEDLINE (Ovid); and Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus, Ebsco). An example of a CINAHL search strategy is included in Box 3. Citations and reference lists of included studies were hand searched to identify addi- tional relevant studies. The first search elicited 15,676 outputs across all databases. Once duplicate results were removed, 11,764 outputs remained. All outputs were exported to Covidence soft- ware (© Covidence 2019) for management. The searching and selection process is sum- marised in the PRISMA diagram (see Fig. 2). Inclusion and exclusion criteria are shown in Table  1. Given the number of outputs identified, non-peer-reviewed outputs were excluded. Box 3 Search strategy example of CINAHL search (supervisor* OR mentors OR mentor OR mentoring OR instructor* OR “placement educator*” OR “practice educator*” OR trainer* OR preceptor OR preceptors OR “clinical teacher*” OR “clinical educator*” or “fieldwork educator*”) N2 (training* OR education OR educating OR workshop*) Supervision N1 (training OR education OR educating OR workshop*) “train the trainer*” (“professional development” OR “faculty development” OR “personal development” OR CPD) N2 (supervisor* OR mentors OR mentor OR mentoring OR instructor* OR “placement educa- tor*” OR “practice educator*” OR trainer* OR preceptor OR preceptors OR “clinical teacher*” OR “clinical educator*” OR “fieldwork educator*”) 1 3 Supervision training in healthcare: a realist synthesis 529 Fig. 2 PRISMA Table 1 Inclusion and exclusion criteria Inclusion criteria Exclusion criteria Relate to one or more of the research questions Literature relating to research supervision Relevant population: literature must relate to either health/health- care, housing, children services, youth and family services and/or mental health disciplines within the health and human service workforces Relevant intervention: literature must relate to supervision train- ing interventions Literature must be written in the English language Peer-reviewed outputs only Primary/empirical research only Study selection and appraisal All authors (except EH) conducted initial assessments of outputs’ relevance using Covi- dence. Each analyst first participated in a calibration exercise of ten titles and abstracts using the inclusion criteria, with subsequent team-based discussions, before analyzing their own set of titles and abstracts. Each author (except EH) then screened a roughly equal 1 3 530 C. E. Rees et al. portion of the titles and abstracts of studies retrieved using the search strategy (and those retrieved from hand searched references) against the inclusion criteria (see Table  1). Any ambiguities at this stage (i.e. outputs selected as ‘maybe’ in Covidence) were checked by a second independent researcher and resolved through discussion (SLL). Five percent of the 11,764 outputs examined for relevance was therefore double-checked at this stage (SLL) (Brennan et al. 2014). Following this initial assessment of relevant titles and abstracts, 77 outputs remained. The full text of these outputs were retrieved and all authors assessed a roughly equal por- tion of outputs for rigour, after first participating in a second calibration exercise involv - ing two full-text outputs, with consequent team-based discussions. Rigour was determined to understand whether the methods used to generate data were credible and trustworthy (Abrams et al. 2018). All authors checked rigour using either the Critical Appraisal Skills Programme (CASP) qualitative checklist (for qualitative or mixed methods studies) (Criti- cal Appraisal Skills Programme 2018), or the Medical Education Research Study Quality Instrument (MERSQI) (for quantitative studies) (Cook and Reed 2015; Reed et al. 2009). At the same time as assessing rigour, we also reexamined relevance based on the full-text outputs, a process which we termed ‘realist relevance’. This meant that the outputs were judged in terms of whether they could contribute to the development of our IPT (Wong et  al. 2013; Abrams et  al. 2018). Assessment of ‘realist relevance’ was based on a 0–3 scale where 0 = the article lacked richness to enable the identification of contexts (C), mechanisms (M), outcomes (O) or context–mechanism–outcome configurations (CMOCs) and could therefore not help in the development of our IPT. At the other end of the scale, a paper received 3 = the article was sufficiently rich to identify CMOCs and could help develop our program theory. Finally, each paper was given an overall judgement (include, exclude, borderline) for rigour and realist relevance combined. Any outputs assessed as borderline for rigour and relevance (approximately 57%) were checked by a second author and any disagreements resolved through discussion (SLL and EH) (Brennan et al. 2014). The final sample of included outputs was 29. Data extraction All authors (except VE and BW) extracted data after a third calibration exercise involv- ing analysts’ extraction of two full-text outputs, with subsequent team-based discussions. The data extraction of the 29 outputs included: study characteristics (e.g. publication year, study methodology); contexts (e.g. study setting, profession, level of supervisor experi- ence, country); intervention characteristics (e.g. content, mode, pedagogical strategies, duration); types of participants (e.g. clinical teachers); mechanisms and outcomes (note that outcomes and/or mechanisms could be positive or negative and pertain to supervisors or supervisees); CMOCs; and MRT. Contexts (C), Mechanisms (M) and Outcomes (O) and CMOCs for each supervision training intervention were highlighted on the 29 outputs and notes added by the data extractors. These highlights and notes were then transferred to tables using Microsoft Word (Microsoft, Windows 10) collating C, M, and Os and CMOCs both within and across our final sample. Note that during this process we labelled out- comes and mechanisms underpinning those outcomes as either positive (+) or negative (-). Inspired by other realist syntheses (Abrams et al. 2018), in order to elicit this informa- tion we made interpretations of meaning (e.g. does the relevant text provide sufficient data that could be interpreted as operating as contexts, mechanisms and/or outcomes?). Seven 1 3 Supervision training in healthcare: a realist synthesis 531 outputs (24%) were double-checked by a second extractor (mostly EH) at this data extrac- tion stage, with any discrepancies resolved through discussion (SLL). Data synthesis To synthesise the large amount of extracted data, we first divided our data into two cat- egories based on the duration of interventions (either short or extended durations), given that intervention duration was flagged as an important intervention component and a mechanism underpinning positive outcomes in our IPT (Fig. 1). Note that short durations were defined as one-off interventions or interventions with multiple sessions but within a restricted time period (e.g. less than 1  week). Conversely, interventions with extended durations were defined as those conducted over many months (and sometimes years), with extended time periods between multiple sessions (e.g. monthly). Microsoft word tables including CMOCs with supporting illustrative quotes from the outputs were used for this data synthesis stage. Led by CER, four authors (CER, SLL, EH and CP) exam- ined the data in these tables to identify demi-regularities (i.e. recurrent CMOCs) (Lee et al. 2019) across the 29 outputs with 139 original CMOCs identified across interventions with short (87 CMOCs) and extended durations (52 CMOCs). Inspired by other realist synthe- ses (Abrams et  al. 2018), we asked questions like: is this CMOC found elsewhere in the same or other documents? How does this CMOC interplay with our IPT? How might this CMOC develop our program theory? Note that at this stage, CMOCs that were considered tangential to these demi-regularities or did not contribute to our MPT were removed from the final tables presented in this paper, leaving 74 final CMOCs (with 42 CMOCs for short- duration interventions, and 32 CMOCs for extended-duration interventions). Results Following the assessment of rigour and realist relevance, 29 outputs remained in the final synthesis based on 28 studies; one study being presented across two outputs (Sandau et al. 2011; Sandau and Halm 2011). The final sample of outputs consisted of eight qualitative, eleven quantitative and ten mixed methods studies. Studies were conducted in various countries including the USA (n = 10), Australia (n = 5), UK (n = 3), Jordan (n = 2), Swe- den (n = 3), Canada (n = 2), Netherlands (n = 1), Taiwan (n = 1) and Pakistan (n = 1), with one paper conducted across multiple counties (Myrick et  al. 2011). Study interventions included face-to-face only (n = 24), online only (n = 4) and blended approaches including face-to-face and online components (n = 1). Interventions were either of short (n = 19) or extended durations (n = 10). There was a vast array of disciplines involved in the final sam- ple including nursing (n = 9), medicine (n = 2) and allied health professions (n = 14), with some outputs including multiple disciplines (n = 4) (e.g. Carlson and Bengtsson 2015). In keeping with our IPT, data extraction and synthesis is presented separately for short (Table 2) and extended-duration interventions (Table 3). Short‑duration supervision training interventions Short-duration supervision training interventions typically focused on learning out- comes relating to supervisory knowledge and skills (content), were delivered face-to- face (mode) and employed multiple approaches such as didactic (e.g. presentations, 1 3 532 C. E. Rees et al. 1 3 Table 2 Data extraction for short-duration interventions References Study methods Intervention Settings Middle-range theories Al-Hussami et al. (2011) Quantitative Knowledge and skills Nursing King’s theory of goal attainment Experimental F2F Clinical instructors (King 1997) 68 registered nurses (RNs) ran- PS: didactic and active learning Hospitals domly assigned to experimental 1 week with 4-h sessions (number Jordan (n = 30) or control group (n = 38) of sessions and time between Objective assessment of their sessions unknown) precepting knowledge Busari et al. (2006) Quantitative Knowledge and skills Medicine: paediatrics, and obstet- None Quasi-experimental F2F rics and gynaecology 27 medical resident preceptors PS: not disclosed Preceptors assigned to an experimental 2 days Teaching hospitals (n = 14) or control group (n = 13) Netherlands Self-perception of the workshop and supervisees’ assessment of preceptors’ teaching Carlson and Bengtsson (2015) Qualitative Knowledge and skills Multiple disciplines: nursing, Adult learning theories (not Interpretive F2F occupational therapy and bio- specified) 27 focus group participants PS: didactic, active and EL medical science Self-perception of the intervention 40 h Clinical preceptors and self-assessment of learning University outcomes Southern Sweden Supervision training in healthcare: a realist synthesis 533 1 3 Table 2 (continued) References Study methods Intervention Settings Middle-range theories Clipper and Cherry (2015) Quantitative Knowledge and skills Nursing Boychuk Duchscher’s theory Quasi-experimental Blended (5 online modules and a Preceptors of transition shock (Boychuk 18 trained and 41 untrained nurs- F2F course) Acute care hospitals Duchscher 2009) ing preceptors PS: didactic, active and EL USA Supervisees’ assessment of 3-h online modules and 1-day preceptors’ teaching and self- course assessment of their own student- to-nurse transition experience Cox et al. (2017) Quantitative Knowledge Pharmacology Adult learning principles (not Experimental, longitudinal Online Adjunct and specified) 187/202 pharmacists completed PS: didactic full-time faculty preceptors, and the evaluation 5–8 min in each video episode (12 novice preceptors Self-assessment of learning episodes in total) Colleges outcomes USA Eckstrom et al. (2006) Qualitative Knowledge and skills Internal medicine None Quasi-experimental, longitudinal F2F Ambulatory preceptors pre/post-test PS: didactic and EL University hospital, Veterans hos- 24 participants (experimental) and half-day pitals, and community sites 44 (control group) USA Supervisees’ assessment of precepting quality and supervi- sors’ self-assessment of learning outcomes Ford et al. (2013) Mixed methods Skills Nursing and midwifery Experiential learning (not speci- Pre- and post-test F2F Junior and senior preceptors fied) 93 nurses and midwives PS: active and EL A 400-bed tertiary referral hospitalReflective practice (not specified) Self-assessment of learning out- 1 day Australia comes and perceptions of being preceptors 534 C. E. Rees et al. 1 3 Table 2 (continued) References Study methods Intervention Settings Middle-range theories Gillieatt et al. (2014) Mixed methods Knowledge and skills Multiple professions: medicine, None Pre- and post-intervention survey F2F nursing and allied health 90/94 participants completed the PS: didactic and active learning Experienced and novice preceptors pre and post surveys 1 day Government and private organisa- Self-assessment of learning tions outcomes Australia Henderson et al. (2006) Qualitative Knowledge and skills Nursing None Longitudinal F2F Novice preceptors 36 registered nurses PS: didactic, active and EL Acute tertiary referral center Subjective assessment of learning 2 days Australia outcomes Hook and Lawson-Porter (2003) Qualitative Knowledge and skills Allied health None Triangulation F2F Novice preceptors 22 allied health professionals PS: didactic and active learning Clinical setting Perceptions of the workshop and 3 days UK self-assessment of learning outcomes Lee et al. (2017) Qualitative Skills Nursing Gagné’s information processing Experimental F2F Novice preceptors theory (Gagné 1985) 13 nurse preceptors (NPs) and 11 PS: didactic and active learning Teaching hospitals new graduate nurses (NGNs) 10 h Taiwan Objective assessment of learning outcomes, self-assessment and supervisees’ assessment of learning outcomes, and percep- tions of the workshop Supervision training in healthcare: a realist synthesis 535 1 3 Table 2 (continued) References Study methods Intervention Settings Middle-range theories McChesney and Euster (2000) Mixed methods Knowledge and skills Social work Knowles’ adult learning theory Quantitative scales and qualitative F2F Agency based social work field (Knowles 1972) questions PS: didactic and active learning instructors 22 educators 4 h Agencies Perceptions of the course and USA self-assessment of the learning outcomes Methot et al. (1996) Quantitative Skills Mental health None Longitudinal F2F Supervisors 1 manager, 4 supervisors, 7 direct PS: didactic, active and EL A residential facility for persons care staff, and 16 clients 3-h presentation and video view- with developmental disabilities Objective assessment of learning ing (duration of follow-up meet- UK outcomes ing not disclosed) Murphy (2014) Quantitative Knowledge and skills Physical therapy Benner’s novice-to-expert model Survey F2F Clinical educators (Benner 1984) 302 physical therapists PS: EL Workplace is not mentioned Kolb’s experiential learning (Kolb Perceptions of the workshop and 1 day Canada 1984) self-assessment of expected learning outcomes Quirk et al. (1998) Quantitative Knowledge and skills Multiple professions: medicine, None Pre- and post-test, and follow-up F2F nursing, psychology and mid- 223 healthcare professionals PS: didactic, active and EL wifery Self- and objective-assessments of 1 day Clinician preceptors learning outcomes, and percep- Workplaces not disclosed tions of the workshop USA 536 C. E. Rees et al. 1 3 Table 2 (continued) References Study methods Intervention Settings Middle-range theories Sandau et al. (2011); Sandau and Mixed Methods Knowledge and skills Nursing None Halm (2011) Quasi-experimental: pre- and F2F Novice preceptors Novice-to-expert framework post-test with qualitative com- PS: didactic and active learning Hospital (Benner 1984) ments 8 h USA Adult learning theory (not speci- 131 preceptors (experimental) and fied) 74 (control group) Self-assessment of the learning outcomes, perceptions of the workshop, and supervisees’ per- ceptions of their orientation Sayani et al. (2017) Mixed methods Knowledge and skills Midwifery None Quantitative: pre- and post-test F2F Novice preceptors and qualitative interviews PS: not disclosed Community 50 midwives 2 days Pakistan Objective assessment of learning outcomes, perceptions of men- toring and willingness to precept Taylor et al. (2007) Mixed methods Knowledge Pharmacology None Likert scale, free-text questions Online Rural pharmacy preceptors and focus groups PS: didactic and active learning Community and hospital 15 pharmacist preceptors 10–20 h Australia Perceptions of the programme and self-assessment of learning outcomes F2F face-to-face; PS pedagogical strategies; EL experimental learning; h hours Supervision training in healthcare: a realist synthesis 537 1 3 Table 3 Data extraction for extended-duration interventions References Study methods Intervention Settings Middle-range theories Halabi et al. (2012) Qualitative Knowledge and skills Nursing Kolb’s experiential learning (Kolb Longitudinal design F2F Nursing preceptors 1984) 12 nursing preceptors PS: didactic, active and EL Governmental and private hos- Dewey’s theoretical ideas of Self-assessment of learning 1-week teaching phases with pitals education as integration between outcomes monthly 5-h meetings in Jordan theory, practice, reflection and between action (Dewey 1964) Schön’s reflective practice (Schön 1987) Milne and Westerman (2001) Quantitative Skills Mental health nursing Kolb’s experiential learning (Kolb Observational and longitudinal F2F Supervisor 1984) design PS: active and EL Community 1 consultant, 1 supervisor, and 3 Hourly weekly meetings over an UK supervisees 8-month period Objective assessments of learning outcomes Myrick et al. (2011) Qualitative Skills Nursing Learning theory (non-specified) 9/18 preceptors participated in Online Preceptors Experiential learning (non- semi-structured interviews PS: didactic and active learning 4th year of undergraduate nursing specified) Perceptions of the e-learning 5 months program technology and self-assessment Australia, Brazil, China, Hong of learning outcomes Kong, Pakistan, UK and USA Ögren et al. (2008) Qualitative Knowledge and skills Psychotherapy Psychodynamic theory (not speci- Longitudinal design F2F Novice preceptors fied) 3 facilitators and 6 novice supervi- PS: didactic, active and EL Workplace not disclosed sors 2 years (theoretical seminars 2-h Sweden Self-assessment of group weekly and group supervision 2-h weekly) 538 C. E. Rees et al. 1 3 Table 3 (continued) References Study methods Intervention Settings Middle-range theories Paulson and Casile (2014) Mixed methods Knowledge and skills Rural mental health None Pre- and post-test survey F2F Rural supervisors 40 nursing preceptors PS: didactic and EL Rural areas Self-assessments of learning 1-day supervision workshop plus USA outcomes and mental state 6-month monthly follow-up peer group supervision training sessions Rogers and McDonald (1992) Quantitative Knowledge and skills Social work Schön’s reflective practice (Schön Quasi-experimental F2F Field instructors 1987) 25 field instructors (experimental) PS: didactic, active and EL Workplace not disclosed and 25 (control group) 20 h across 10 weeks Canada Objective assessment of learning outcomes Seo and Engelhard (2014) Mixed methods Knowledge and skills Physical therapy Knowles’ adult learning theory Quasi-experimental Online Clinical instructors (Knowles 1990) 21 physical therapist clinical PS: active learning A public university Self-regulated learning (not instructors in experimental 9 weeks USA specified) group and 24 in control group Self-assessment of learning outcomes Sevenhuysen et al. (2013) Mixed methods Skills Physiotherapy Peer-assisted learning (not speci- Participatory research F2F Clinical educators fied) 14 clinical educators PS: didactic and active learning Five hospital campuses and com- Self-assessment of learning 2 h for each workshop (a series of munity health and rehabilitation outcomes and perceptions of the 4 workshops with unclear tim- centres workshop ings in-between) Australia Supervision training in healthcare: a realist synthesis 539 1 3 Table 3 (continued) References Study methods Intervention Settings Middle-range theories Sundin et al. (2008) Quantitative Knowledge and skills Psychotherapy Proctor and Inskipp’s theory Quasi-experimental F2F Novice supervisors (Proctor and Inskipp 2001) 21 supervisors and 6 facilitators PS: didactic and EL Workplace not disclosed Self-assessment of learning 2 years (group supervision is 2 h Sweden outcomes and perceptions of weekly: total 140 h duration) supervisor styles Tebes et al. (2011) Quantitative Knowledge and skills Social work Shulman’s interactional theory of Quasi-experimental: pre- and post-F2F Clinical supervisors clinical supervision (Shulman intervention follow-up with no PS: didactic and active learning Non-profit behavioural health 1991, 1993, 2005) comparison group 7-month duration (approximately agencies 81 social workers 28 h or 5 days) USA Perceptions of the training, self- assessment of learning outcomes 540 C. E. Rees et al. videos), active (e.g. group discussions, case studies, reflection activities) and experi- ential learning (e.g. role plays, feedback). Although MRTs underpinning short inter- ventions were often absent or not specified in the outputs, a range of theories were identified, the most common of which were adult learning theories (Knowles 1972), experiential learning (Kolb 1984) and the novice-to-expert model (Benner 1982). Ten demi-regularities pertinent to our developing program theory were identified from the wide-ranging CMOCs identified in the extraction phase, with eight demi-regu- larities highlighting interventions’ positive outcomes and two demi-regularities illustrat- ing interventions’ negative outcomes (see Table  4). In terms of the positive outcomes, all but one of the identified demi-regularities related to supervisor outcomes: Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced improved satisfaction with training [+ O] (Hook and Lawson-Porter 2003; McChesney and Euster 2000; Murphy 2014); improved supervisory confidence [+ O] (Carlson and Bengtsson 2015; Ford et al. 2013; Taylor et al. 2007); improved supervisory engagement [+ O] (Cox and Araoz 2009; McChesney and Euster 2000; Taylor et al. 2007) and improved supervisory knowledge and practices [+ O] (C Cox et al. 2017; Ford et al. 2013; Gillieatt et al. 2014; Henderson et al. 2006; Hook and Lawson-Porter 2003; Lee et  al. 2017; Methot et  al. 1996; Murphy 2014) through mixed pedagogical strategies including active and/or experiential learning [+ M]. • Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced improved supervisory practices [+ O] through improved knowledge, skills and/or attitudes [+ M] (Carlson and Bengtsson 2015; Taylor et al. 2007). Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced improved supervisory practices [+ O] through improved confidence and/or self-efficacy [+ M] (Carlson and Bengtsson 2015; Eckstrom et al. 2006). • Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced improved supervisory satisfaction, knowledge, practices [+ O] through posi- tive social relationships [+ M] (Gillieatt et  al. 2014; Henderson et  al. 2006; Hook and Lawson-Porter 2003; McChesney and Euster 2000). The remaining demi-regularity relating to positive outcomes spoke to supervisee outcomes: • Healthcare supervisors [C] undergoing short-duration supervision training [I] helped improve supervisee development and well-being (e.g. retention) [+ O] through struc- tured training [+ M] (Clipper and Cherry 2015; Sandau et al. 2011). The demi-regularities that resulted in negative outcomes pertained only to supervi- sor-related outcomes: Healthcare supervisors [C] undergoing short-duration supervision training [I] expe- rienced no improvements in supervisory skills [− O] through lack of engagement in training or reinforcement of training [− M] (Busari et  al. 2006; Eckstrom et  al. 2006; Quirk et al. 1998). Healthcare supervisors [C] undergoing short-duration supervision training [I] experi- enced poor supervisor engagement in training [− O] through insufficient protected time [− M] (Hook and Lawson-Porter 2003; Sandau and Halm 2011; Sayani et al. 2017). Based on these demi-regularities we developed a modified program theory (MPT) for short-duration interventions (Fig. 3). 1 3 Supervision training in healthcare: a realist synthesis 541 1 3 Table 4 CMOCs for short-duration interventions Reference CMOC Illustrative quote (page number) Busari et al. (2006) Medical residents [C] who attended the 2-day teaching workshop [I] did not “The post-workshop ratings, however, showed no significant difference show significant improvement in teaching ability [− O] because of incomplete in teaching ability between the experimental group and the control participation in the workshop [− M] group. Possible explanations for this finding could be the consider - able drop-out… ill health, maternity leave, graduation, external clini- cal rotations and incomplete participation in the workshop.” (p. 140) Carlson and Bengtsson Participants [C] undergoing the CPD course [I] expressed their growth in self- “The participants explained, in interviews and reflective journals, (2015) confidence in relation to the preceptor role [+ O] through multiple learning how they had gained self-confidence in relation to the preceptor role activities [+ M] through the different learning activities.” (p. 4) Preceptors [C] undergoing the CPD course [I] expressed that they would “It was also described that the new knowledge and skills would be put implement new educational models for students [+ O] due to newly acquired to use to… implement new educational models for students.” (p. 4) knowledge and skills [+ M] Preceptors [C] undergoing the CPD course [I] improved precepting behaviours “Reflective journals as well as discussions in the focus groups dis- [+ O] as the preceptors had experienced an increased confidence in their closed how participants experienced an increased trust in their abili- abilities as preceptors [+ M] ties as preceptors. This was described as having gained inner strength and the courage to try new approaches to precepting.” (p. 4) Preceptors [C] undergoing the CPD course [I] improved preceptor behaviours “After participating in the course they [preceptors] expressed how the [+ O] as they had gained new knowledge and improved communication skills new knowledge and the improved communication skills helped them [+ M] to be better prepared and courageous in situations they perceived as difficult.” (p. 4) Preceptors [C] undergoing the CPD course [I] shifted their didactical approach “The preceptors perceived that they had gained more understanding of from teacher-oriented to learner-oriented [+ O] as they had gained more how they could use reflection as an educational tool working with the understanding of how they could use reflection [+ M] students. They explained that their didactical approach had shifted from teacher-oriented to learner-oriented.” (p. 5) Clipper and Cherry Nurse graduate supervisors [C] who participated in a preceptor-training pro- “A structured preceptor-training program may contribute to an (2015) gram [I] may contribute to an improved transition to practice and improved improved transition to practice and improved first-year retention rates first-year retention rates of NGRNs [+ O] due to structured preceptor-training of NGRNs.” (p. 448) program [+ M] 542 C. E. Rees et al. 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) Cox et al. (2017) Given the various learning styles of each pharmacist preceptor [C], the online “Given the diversity of individual approaches to learning, we believe video mini-series [I] reached a broader audience [+ O] because the mini- blended learning has the potential to more successfully reach a series provide content in both written and video formats [+ M] broader audience. Although this cannot be definitively said, the mini- series did provide content in both written and video formats.” (p. 9) Pharmacist preceptors [C] undergoing the online video mini-series [I] actively “By requiring participants to think about a particular situation and how participated in reflection questions [+ O1] enabling them to apply the content it would apply to them or their practice, they were able to process the to their preceptor role [+ O2] through the content relating to their experiences educational content in a way that enabled them to more easily apply or hypothetical situations [+ M1] the content in their role as a preceptor.” (p. 10) Eckstrom et al. (2006) Internal medical preceptors [C] who participated in the 1-min preceptor (OMP) “Faculty who participated in our workshop felt that they increased their workshop [I] experienced increased use of the OMP teaching skills over the use of the OMP teaching skills over the next 6 months. Faculty per- next 6 months [+ O] because their self-efficacy helped the continued perfor - ception of self-efficacy is critical to continued performance of newly mance of newly learned skills [+ M] learned skills.” (p. 412) Internal medical preceptors [C] who have participated in the 1-min preceptor “Because faculty are habituated to a particular teaching practice, they (OMP) workshop [I] fell back to their previous patterns of supervisory behav- may make early changes after what they consider successful faculty iours [− O] if their new skills were not reinforced [− M] development intervention, and then fall back into previous patterns of behaviour if the new skills are not reinforced.” (p. 413) Ford et al. (2013) Nursing and midwifery preceptors [C] participating in a 1-day workshop [I] “There is evidence of an interconnectedness between the development increased their preceptorship confidence, knowledge and skills [+ O] based of knowledge and skills of the nurses and midwives and the enabling on the practice development approach [+ M] strategies that are utilised in the delivery of the program. Once again, these features of the program are also features of a Practice Develop- ment approach.” (p. 12) Gillieatt et al. (2014) Health professionals [C] participating in a 1-day training program [I] reported “The challenges associated with the simultaneous application of the that their self-rated supervisory skills had changed as a result of the training three functions were explored through practice exercises using sce- [+ O] through engagement with practical exercises [+ M] together with feed- narios and through feedback from peers and trainers” (p. 4) back from peers and colleagues [+ M] Health professionals [C] participating in a 1-day training program [I] reported “… reported that their skills had definitely changed (41%) or mostly that their supervisory knowledge and skills had improved [+ O] through changed (42%) post-training… feeling empowered, confident and increased confidence [+ M] enthusiastic; being more comfortable in the role of supervisor and having increased knowledge and skills.” (pp. 5–6) Supervision training in healthcare: a realist synthesis 543 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) Henderson et al. (2006)RN preceptors [C] undergoing the 2-day preceptor training [I] increased “One of the benefits perceived by the preceptors was their opportunity knowledge about the preceptor role [+ O] due to the benefit of learning from to learn from others. Some found that they learned from both new others [+ M] graduates and more experienced transfers.” (p. 133) Hook and Lawson- Multiprofessional field work educators [C] involved in a 3-day fieldwork educa- “…practitioners identified that their practice with students had changed Porter (2003) tor course [I] felt their educator and practitioner roles had changed positively positively, being more reflective with the use of learning styles [+ O] due to being more reflective on learning styles and supervision [+ M] and supervision skills. Some felt that they had changed in areas of practice within their role as a practitioner and not just within their educator role.” (p. 535) Multiprofessional field work educators [C] involved in a 3-day fieldwork educa- “…most practitioners found the pressures of their workload and tor course, plus reflective portfolio assignment [I] reported difficulty finishing domestic life difficult to balance with the pressures of completing an assignment and course requirements [− O] because their service managers assignment… not all participants were given study time to enable provided insufficient study time after the face-to-face session [− M] them to complete their portfolio.” (p. 535) Multiprofessional field work educators [C] involved in a 3-day fieldwork educa- “…the multi-professional and therapy-led nature of the course was tor course [I] were satisfied with the course [+ O] due to the opportunity to well received. Participants welcomed the opportunity to share and share and discuss with other health professions [+ M] integrate with other professionals and experience a programme that was relevant to their practice.” (p. 535) Multiprofessional field work educators [C] involved in a 3-day fieldwork educa- “Some used their mentors in the early stages of the assignment to tor course [I] were able to clarify ideas and consolidate work [+ O] because clarify ideas and help guide their thinking. Others used their mentors they engaged with their post-course mentor well [+ M] to consolidate their work and gain reassurance that their reflections were addressing the learning outcomes appropriately.” (p. 535) Lee et al. (2017) The nursing preceptors [C], after taking the training course including video “On the basis of the results of the focus group interviews with the NPs, instruction and reflections [I] experienced a strong pedagogical effect [+ O] the current authors thought that using nine instructional events… because multiple teaching skills were presented in the course rather than along with video instruction and reflections would have a strong using lectures alone [+ M] pedagogical effect.” (pp. 226–227) The nursing preceptors [C] who participated in the training course [I] had their “The reflection quizzes were all based on the content of the courses, learning reinforced [+ O] after taking the course content-based quizzes [+ M] reinforcing their influence.” (p. 227) 544 C. E. Rees et al. 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) McChesney and Euster Social work fieldwork instructors [C] involved in a 4-h workshop [I] felt the “Active learning methods were perceived to promote feelings of high (2000) workshop had high productivity, involvement and safety [+ O] because of the productivity, high involvement and high safety for participation use of active learning methods [+ M] among field instructors.” (p. 201, abstract) “Brief lectures and discussion related to materials provided in the Social work fieldwork instructors [C] involved in a 4-h workshop [I] partici- pated in active discussion and effective interaction [+ O] due to brief lectures resource guide appeared to stimulate active discussion and effective and discussion related to resource material [+ M] interaction.” (p. 212) Social work fieldwork instructors [C] involved in a 4-h workshop [I] engaged “Case vignettes and accompanying questions served to stimulate in critical thinking and helpful discussion [+ O] due to prompts for reflective critical thinking and helpful discussion. The cases promoted discus- practice [+ M] sion not only about specific practice dilemmas, but also about field instructor’s own experiences with similar situations and how they had been resolved.” (p. 213) Social work fieldwork instructors [C] involved in a 4-h workshop [I] were satis- “The small size of the seminar groups provided the opportunity for fied [+ O] and able to participate in constructive group discussion [+ O] due constructive group discussion. Most of the seminar participants to the interactions amongst small group/small participant numbers [+ M] actively engaged in discussion of field practicum issues.” (p. 213) Social work fieldwork instructors [C] involved in a 4-h workshop [I] were satis- “Each group read and discussed among themselves the ethical and fied with and enjoyed discussion about a topic [+ O] due to the interaction legal dilemmas… Participants appeared to enjoy the interaction and with peers and exchange of views in a peer teaching activity [+ M] exchange of views that this teaching method provided. They studied the article section assigned to them and lively discussion ensued.” (p. 213) Methot et al. (1996) Mental health supervisors [C] experiencing training videos demonstrating “… it takes little time to verify on-the-job use of the performance feed- 10 components of a formal supervision meeting [I] achieved considerable back skills by trained supervisors. A great deal of behaviour change behaviour change at the direct staff and client levels [+ O] as the supervisors at staff and client levels can be achieved with a small amount of time and managers only needed to spend little time watching the videos to verify invested in appropriate training at upper levels in the organization.” their on-the-job use of performance feedback skills [+ M] (p. 21) Mental health supervisors [C] experiencing training videos [I] showed variabil- “The variability in behavior levels for most subjects is apparent and ity in behaviour [− O] through the amount and types of other duties involved should be qualified in terms of the amount and types of other duties in managing, supervising and delivering direct care to developmentally involved in managing, supervising and delivering direct care… disabled clients [− M] Because of these additional duties… one would not expect to find stable data on delivery of contingent consequences across observa- tions.” (p. 21) Supervision training in healthcare: a realist synthesis 545 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) Murphy (2014)) Physical therapy clinical educators [C] participating in a hands-on workshop “role play… [where] participants formed triads, with one person taking [I] were satisfied with the workshop [+ O] and had an increased perception of the student role, one the educator and one the observer… role-play readiness and comfort to provide student learning [+ O] through role playing was the most valuable thing learned.” (p. 338) communication and conflict resolution [+ M] Quirk et al. (1998) Community health preceptors [C] attending a 1 day face-to-face workshop [I] “Retention rates should decrease as complexity of the initial learning decreased the retention rate of teaching behaviours over time [− O] when increases. In this regard one would expect the use of the teaching complexity of initial learning increased [− M] behaviours presented at the workshop might decrease over time more so than familiarity with the concepts.” (p. 707) Community health preceptors [C] undergoing a 1 day face-to-face short devel- “Further studies are needed to see whether a booster session or incen- tives might help preceptors to maintain appropriate use of teaching opment workshop intervention using the education planning process [I] might maintain their appropriate use of teaching behaviours [+ O] because a booster behaviours… This would be especially important in situations where session or incentive might reinforce learning and knowledge [+ M] the faculty intervention is short and the expected change in behaviour is complex.” (p. 707) Preceptors from community health centres [C] attending a 1 day face-to-face “Community health centres can increase their familiarity with concepts workshop [I] can increase their familiarity with concepts [+ O] and their and their ability to use behaviours a result of a brief inter-disciplinary ability to use behaviours [+ O] as a result of a brief faculty development faculty development intervention”. (p. 707) intervention [+ M] Sandau et al. (2011) Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “Cohort 2 preceptors… At 3–6 months… Results for confidence and workshop [I] had increased confidence, understanding and abilities in pre- comfort in all five roles were significantly improved…” (p. 122) cepting new nurses [+ O] through workshop participation [+ M] Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “… nurses in Cohort 2—orientees reported significantly greater workshop [I] helped nursing orientees to increase their confidence on com- confidence on completion of the first assignment after completing pleting their first assignment [+ O] through supervisors completing training orientation compared with Cohort 1—orientees…” (p. 123) [+ M] Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “… Cohort 2—orientees reported greater confidence in the use of criti- workshop [I] helped nursing orientees to increase their confidence in critical cal thinking on completion of orientation… than did nurses new to thinking [+ O] through supervisors completing training [+ M] the hospital.” (p. 123) 546 C. E. Rees et al. 1 3 Table 4 (continued) Reference CMOC Illustrative quote (page number) Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “At 1 year post intervention, the proportion of new nurses (125 of 132) workshop [I] helped nursing orientees’ retention within the hospital within retained was significantly greater than in the previous year (82 of a year of commencing their new role [+ O] through supervisors completing 94).” (p. 123) training [+ M] Sandau and Halm Nurses from a large hospital [C] who participated in a mandatory 8-h preceptor “However, the quality of some preceptors was described as subpar, (2011) workshop [I] led to nursing orientees experiencing negative orientation [− O] often because of lack of time.” (p. 176) because their preceptors did not have protected supervision time [− M] Nursing preceptors [C] undergoing the workshop [I] had a negative precept- “Mismatched schedules of preceptors and orientees, as a result of 8- ing experience [− O] because of mismatched schedules of preceptors and versus 12-h shifts, rotating shifts, or preceptor vacation time, were orientees [− M] cited as barriers to effective precepting.” (p. 179) Sayani et al. (2017) Midwifery participants [C] who have attended a 2-day mentorship workshop [I] “The reasons for not beginning to work as a mentor were cited as busy did not begin to work as a mentor [− O] because they were occupied by other work schedule, attending other training sessions, and personal com- commitments [− M] mitments.” (p. 516) Taylor et al. (2007) The pharmacist preceptors [C], after participating in the online programme [I], “Many participants experience a change in attitude to their role of experienced positive preceptor–preceptee relationships [+ O] as they changed being a preceptor and this indirectly affected his/her ability with the their attitudes to their role of being a preceptor [+ M] students.” (p. 51) The pharmacist preceptors [C] undergoing the online programme [I] can now “All groups voiced their appreciation for the flexible delivery mode access the training [+ O] as it is flexible in its delivery mode [+ M] of the program which enabled them to access an educational course from their rural location.” (p. 50) The pharmacist preceptors [C] after undergoing the online programme [I] “For many, their prior experiential learning was validated, reinforced experienced confidence growth in their abilities to be an effective precep- and extended and lead to a subsequent increase in confidence in their tor [+ O] as their prior experiential learning was validated, reinforced and abilities to be an effective preceptor.” (p. 51) extended [+ M] NGRN new graduate registered nurse; RN registered nurse; NP nursing preceptor Supervision training in healthcare: a realist synthesis 547 Extended‑duration supervision training interventions Extended-duration supervision training interventions also typically focused on partici- pants developing their supervisory knowledge and skills (content), were delivered face- to-face (mode) and employed multiple approaches such as didactic (e.g. presentation, videos, reading), active (e.g. group discussions, reflective activities) and experiential learning (e.g. group supervision). Indeed, differences between short and extended-dura- tion interventions (other than their longevity) were subtle, including: (1) some short- duration interventions being delivered online, and (2) more extended-duration interven- tions employing experiential pedagogical strategies. Although middle-range theories underpinning extended-duration interventions were sometimes absent or not speci- fied in the outputs (e.g. ‘learning theory’, ‘psychodynamic theory’), various theories were identified. The most commonly identified were experiential learning (Kolb 1984), reflective practice (Schön 1987), and social learning theories (Proctor and Inskipp 2001; Shulman 1991, 1993, 2005). We were able to identify fewer demi-regularities across our wide-ranging CMOCs for extend-duration interventions (Table 5). Firstly, we found five demi-regularities consistent with those already identified above for short-duration interventions but these were some- times expressed in the reverse way (e.g. negative outcomes for extended but positive out- comes for short-duration interventions): Healthcare supervisors [C] undergoing extended-duration supervision training [I] expe- rienced improved supervisory knowledge and practices [+ O] through mixed pedagogi- cal strategies emphasizing active and/or experiential learning [+ M] (Halabi et al. 2012; Myrick et al. 2011; Ögren et al. 2008; Rogers and McDonald 1992; Seo and Engelhard 2014). • Healthcare supervisors [C] undergoing extended-duration supervision training [I] expe- rienced modest outcomes only [− O] through a lack of systematic training involving mixed pedagogical strategies [− M] (Milne and Westerman 2001; Rogers and McDon- ald 1992). • Healthcare supervisors [C] undergoing extended-duration supervision training [I] experienced improved supervisory knowledge and practices [+ O] through supervisor engagement [+ M] (Tebes et al. 2011). Healthcare supervisors [C] undergoing extended-duration supervision training [I] expe- rienced poor supervisor engagement in training [− O] through insufficient protected time [− M] (Ögren et al. 2008). • While healthcare supervisors [C] undergoing extended-duration supervision training [I] experienced improved supervisory satisfaction, knowledge, practices and/or atti- tudes [+ O] through positive social relationships [+ M] (Myrick et al. 2011; Ögren et al. 2008; Sundin et al. 2008), they experienced modest outcomes only [− O] through chal- lenging social relationships [− M] (Milne and Westerman 2001; Ögren et al. 2008). We identified only one additional demi-regularity for the extended-duration interven- tions, not prominent for short-duration interventions: While healthcare supervisors [C] undergoing extended-duration supervision training [I] experienced improved supervisory engagement, knowledge and/or practices [+ O] through positive facilitator styles [+ M] (Myrick et al. 2011; Ögren et al. 2008; Sundin et  al. 2008; Sevenhuysen et  al. 2013), they experienced modest outcomes only [− O] through negative facilitator styles [− M] (Sundin et al. 2008). 1 3 548 C. E. Rees et al. Fig. 3 Modified program theory—short duration intervention Based on these demi-regularities we developed a MPT for extended-duration interven- tions (Fig. 4). Discussion This synthesis set out to address the research questions: to what extent do supervision train- ing interventions work (or not), for whom and in what circumstances, and why? Through our realist synthesis of 29 research outputs, we were able to develop two novel program theories, grounded in that evidence, about the positive and negative outcomes of short and extended-duration supervision training interventions, the mechanisms underpinning those outcomes and the extent to which those relationships were context-dependent, thereby developing existing knowledge on supervision training interventions. Summary of key findings The developed program theories demonstrate that both short and extended-duration super- vision training interventions have a multiplicity of positive supervisor outcomes including improved satisfaction, knowledge, skills, and engagement through a combination of mech- anisms including mixed pedagogical approaches involving active and/or experiential learn- ing, plus privileging social relationships (e.g. teacher–learner, peer–peer). Furthermore, both modified program theories illustrate that short and extended-duration supervision training interventions can lead to poor supervisor engagement in training when insufficient protected time exists for supervisor learning. Additionally, while most of the literature reviewed originated from health professions rather than human services contexts, we did not find that variations in disciplinary or organisational contexts were especially relevant to 1 3 Supervision training in healthcare: a realist synthesis 549 1 3 Table 5 CMOCs for extended-duration interventions References CMOC Illustrative quote (page number) Halabi et al. (2012) Female registered nurses with more than 5 years’ clinical experience [C] “The participants described how the pedagogical strategies improved undergoing a metropolitan university based part-time preceptor training their teaching in the practice area” (p. 139) program over 6 months (1 week every 3 months) [I] had improved their clinical teaching and capacity to guide students to integrate theory and practice [+ O] through the learning environment facilitating experiential learning pedagogies [+ M] Female registered nurses [C] undergoing a part-time preceptor train- “In addition, most participants noted that they became better prepared to ing program over 6 months [I] had improved their ability to manage manage challenging learning situations while attending the program” challenging learning situations [+ O] through the learning environment (p. 140) facilitating experiential learning pedagogies [+ M] Female registered nurses [C] undergoing a part-time preceptor training “Participants reported… improved communication skills with col- program over 6 months [I] had improved their communication skills leagues, students, and hospital staff” (p. 141) [+ O] through the learning environment facilitating experiential learning pedagogies [+ M] Female registered nurses [C] undergoing a part-time preceptor training “The participants stated that learning became easier and more fun when program over 6 months [I] had improved student supervisees’ active their students could share their ideas in a group discussion.” (p. 140) involvement in group supervision sessions [+ O] through preceptors’ applying experiential learning pedagogies into group supervision [+ M] Milne and Westerman The supervisor [C] after undergoing the 8-month 1-h weekly consultancy “Frisch (1989) used a carefully designed 40 h module to develop super- (2001) and feedback [I] only received a modest outcome from the supervision vision skills… This included handouts and audio–visual aids, in con- activities [− O] because the consultancy was not sufficiently systematic junction with diverse teaching methods… Comparison with these two [− M] examples indicates, therefore, that the present study may have had its relatively limited impact because the consultancy was not sufficiently systematic.” (p. 454) The supervisor [C] after undergoing the 8-month 1-h weekly consultancy “… experiential learning methods are inherently challenging… effortful, and feedback [I] only received a modest outcome from the supervision and carry with them a considerable degree of uncertainty as to the activities [− O] because the supervisees prefer amicable supervisor– outcome… This creates the conditions for the supervisees to counter- supervisee relationships and exert a certain degree of influence over the control or collude with the supervisor, as both parties would be more supervisor–supervisee relationship [− M] comfortable with the more supportive and non-threatening methods of learning…” (p. 454) 550 C. E. Rees et al. 1 3 Table 5 (continued) References CMOC Illustrative quote (page number) The supervisor [C] after undergoing the 8-month 1-h weekly consultancy “… supervisees… experienced considerable stress in trying to imple- and feedback [I] only received a modest outcome from the supervision ment the PSI [psychosocial intervention] methods… the supervisor activities [− O] because the supervisor did not want to put too much often felt overwhelmed by the welter of stressors brought into supervi- pressure on already stressed supervisees [− M] sion sessions… a collusive relationship was possibly shaped by nega- tive reinforcement on both sides… an important threat to evidence- based supervision” (p. 455) Myrick et al. (2011) The nursing preceptors [C] undergoing the e-learning technology [I] “The social presence was ensured through the provision of a full time were engaged to reflect on information [+ O1] and acquired precepting facilitator who engaged the participants in both synchronous and asyn- knowledge [+ O2] because a full-time facilitator interacted with them chronous discussion and interactive sessions throughout the trajectory and ensured that they engaged in dialogue that was current, relevant, of the program…” (p. 265) supportive and connected [+ M1] The nursing preceptors with lower computer literacy [C] undergoing the “The Virtual Space. [I]tself was found by the preceptors to be challeng- e-learning technology [I] acquired technological skills and ability [+ O] ing and engaging while at the same time it was also found to provide due to the opportunity to enhance their individual skill in the use of them with an opportunity to enhance their individual skill in the use of technology [+ M] technology.” (p. 265) The nursing preceptors [C] who received the e-learning technology [I] “In the planning of this online preceptorship support program, an experienced interaction, learning and growth [+ O] due to the careful instructional designer with a background in educational theory was planning and integration of instructional strategies orchestrated by a consulted so that the appropriate learning tools could be adopted to competent instructional designer [+ M] facilitate an effective learning experience of the preceptors.” (p. 266) Ögren et al. (2008) When supervisors [C] undergoing the 2-year training program [I] were “… supervisors believed that it was important that they assumed a slow at understanding, the facilitators could help supervisors find their humble attitude when they did not understand something that was own pace of understanding [+ O] and alternative ways of seeing [+ O] expressed during the supervision. It was considered essential to wait when the facilitators were humble and patient [+ M] for the supervisees and to let each of them find their own pace of understanding what was happening in the interplay.” (p. 12) The supervisors [C] undergoing the 2-year training program [I] had posi- “The supervisees generally experienced that the program supervisors tive experiences of finding their paths to solutions [+ O] as the facilita- had actively sought to create space for the supervisees to reflect and tors gave them space to reflect and think [+ M] ponder. Supervisees were given the opportunity to find their own paths to solutions” (p. 13) Supervision training in healthcare: a realist synthesis 551 1 3 Table 5 (continued) References CMOC Illustrative quote (page number) The supervisors [C] who underwent the 2-year training program [I] expe- “Something that contributed to security and quality in supervision was rienced security and quality in supervision [+ O] because the facilitator that the supervisor was direct and expressed him or herself clearly was direct and expressed themself clearly without being offensive [+ M] without being offensive” (p. 14) The supervisors [C] who underwent the 2-year training program [I] “This attitude [of openness and curiosity] was experienced as having experienced an attitude of openness and curiosity when sharing their contributed to an increased confidence… To feel free to talk about problems [+ O] through increased confidence [+ M] and feeling free to one’s work, to be able to associate with colleagues without being talk about their work without fear of judgement [+ M] scared of being “right or wrong,” was emphasized as being important and a worthwhile aim.” (p. 13) The supervisors [C] undergoing the 2-year training program [I] could feel “An extremely passive style could, however, create insecurity amongst insecurity [− O] if the facilitators were extremely passive in style [− M] the supervisees.” (p. 14) Supervisors [C] undergoing the 2-year group training program [I] “Each group member is given the opportunity to follow the development improved their understanding that one situation could be managed in of the other prospective supervisors and their respective therapists various ways [+ O] through listening and thinking about lots of perspec- and clients over time. It becomes clear that one can manage similar tives on situations [+ M] situations in various ways depending on the particular circumstances.” (p. 15) “Many supervisees reported that the interplay with the group members, The supervisors [C] in the 2-year training program [I] were led to new ideas and associations [+ O] through the interplay with other group which included giving attention to their presentations and receiv- members [+ M] ing their views on their work, gave them new ideas and associations related to their own work” (p. 17) The supervisors [C] who underwent the 2-year training program [I] were “Competition for time and a perceived lack of space contributed periodi- struggling to find their place in the group [− O] as they were aware that cally to difficulties for supervisees in finding their place in the group” each member’s time was limited [− M] (p. 18) The supervisors [C] undergoing the 2-year training program [I] success- “Thus, this study provided support for the idea that supervision of pro- fully shifted their perspective from being a psychotherapist to a supervi- spective supervisees combined with theoretical seminars, in a unique sor [+ O] through the training program combining theoretical seminars way, contributes to this type of shift in perspective among supervi- and group supervision [+ M] sees” (p. 19) 552 C. E. Rees et al. 1 3 Table 5 (continued) References CMOC Illustrative quote (page number) Paulson and Casile (2014) Rural mental health supervisors [C] undergoing a 1-day supervision train- “Overall, the group began without high levels of burnout and isolation, ing plus 6 monthly peer group supervision sessions [I] had decreased but still grew positively throughout the 6 months… the results suggest emotional exhaustion [+ O] and decreased depersonalisation [+ O] that the supervisors may have become more energised, connected, and because they became more energized, connected and confident through- confident throughout the peer supervision sessions” (p. 214) out the peer group supervision sessions [+ M] Rogers and McDonald Social work field instructors [C] undergoing a 10-week, 20-h program “This type of learning assignment, which forced them to actually reflect, (1992) [I] had improved their ability to discriminate between truth and falsity consider, and articulate their inferences, might account for the increase [+ O] because of the pedagogical techniques employed facilitating in ability” (p. 174) supervisor reflection on inferences [+ M] Social work field instructors [C] undergoing a 10-week program [I] had “The intent was to provide a learning environment and learning experi- improved critical thinking [+ O] through the learning environment ences that would facilitate and encourage critically reflective field facilitating critical reflection [+ M] instruction methods and practices” (p. 174) Social work field instructors [C] undergoing a 10-week program [I] “There was little emphasis in the course in terms of content, exercise, or showed no improvements in their abilities to determine if conclusions assignments on deduction, or on interpretation which may explain why follow from information [− O] and no improvements in abilities to there was no significant change in those areas” (p. 174) weigh evidence and decide whether conclusions are warranted [− O] because the course materials did not emphasise deduction or interpreta- tion aspects of critical thinking [− M] Seo and Engelhard (2014) Physical therapy clinical instructors [C] engaging in an online continu- “The online module evoked motivation, critical thinking, self-directed ing education module [I] experienced perceptions of improved student learning, and self-reflection and that the participants perceived an mentoring quality [+ O] because of evoked motivation, critical thinking, improvement in the quality of student mentoring.” (p. 49) self-directed learning and self-reflection [+ M] Sevenhuysen et al. (2013) Physiotherapy clinical educators [C] undergoing four 2-h workshops to “… this level of engagement was achieved by responding to the con- design and develop a peer-assisted learning (PAL) model of clini- tinual critical review of stakeholder feedback and adjusting the content cal education for paired undergraduate physiotherapy students [I] of the workshops, and the model itself, based on the feedback. It was experienced improved engagement with the peer learning model [+ O] also achieved by allowing “space” for participants to raise concerns because facilitators adjusted the content of workshops, and model, and discuss potential solutions for these concerns” (p. 42) based on feedback [+ M] and provided space during workshops to raise stakeholder concerns and develop solutions for concerns [+ M] Supervision training in healthcare: a realist synthesis 553 1 3 Table 5 (continued) References CMOC Illustrative quote (page number) Physiotherapy clinical educators [C] undergoing four 2-h workshops [I] “Peer assisted learning (educator to educator) was deliberately employed experienced improved engagement with the workshops [+ O] because as a strategy for engaging participants in workshops, as clinical of peer learning strategies used during the workshops as a strategy for educators were encouraged to learn from one another’s experience and engaging stakeholders [+ M] ideas” (p. 36) Sundin et al. (2008) Accredited psychotherapists (who had conducted > 125 psychotherapy “… a supervisor style that was perceived as more decisive (consulta- sessions and practiced for > 3 years post-authorisation) [C] undergoing tive, directive, active, structured) at 6 months contributed to perceived a 2-year part-time psychotherapy training program [I] gained knowledge attainment of psychotherapeutic knowledge and skills at the 18-moth and skills [+ O] through facilitators using more decisive styles [+ M]; measurement” (p. 389). and facilitators adopting authoritative approaches in the early to middle phases of the program [+ M] Accredited psychotherapists [C] undergoing a 2-year part-time psycho- “… the negative association between self-ratings of a theoretical style therapy training program [I] did not help trainees attain knowledge and and knowledge attainment could be taken to suggest that the trainees skills [− O] if their supervisor prioritised a theoretical style [− M] experience the task to integrate supervisory practice with theoretical considerations to be extremely challenging and frustrating” (p. 392) Accredited psychotherapists [C] undergoing a 2-year part-time psycho- “The results suggested that the relationship among trainees was a sub- therapy training program [I] enhanced knowledge and skills [+ O] stantial predictor of attained knowledge” (p. 391) because of the positive relationships in a small group [+ M] Tebes et al. (2011) Licensed social workers with 16 years’ clinical experience and 8 years’ “… training in interactional supervision was associated with significant supervision experience [C] undergoing a 5-day interactional supervision increases in supervisors’ perceived ability to manage supervisory relationships, manage supervisee job performance, and promote the training program over 7 months [I] experienced perceived increases in their competency [+ O] through participating in the training program professional development of their supervisees” (pp. 195–196) and applying learnt skills in their supervision practice [+ M] Licensed social workers [C] undergoing a 5-day training program over “…managing supervisory relationships significantly predicts increases 7 months [I] experienced decreased supervisory stress [+ O] through in supervisor stress management” (p. 195) understanding and applying approaches to managing the supervisory relationship [+ M] Licensed social workers [C] undergoing a 5-day training program over “… increases in supervisor competencies are associated with increased 7 months [I] experienced increased satisfaction with their supervisory supervisor satisfaction… managing supervisory relationships and role [+ O] through understanding and applying approaches to managing managing job performance significantly predict increases in supervisor the supervisory relationship and a decrease in supervisory stress [+ M] satisfaction” (p. 195) 554 C. E. Rees et al. our program theories for short or extended-duration interventions. However, when compar- ing the mechanisms underpinning short and extended-duration training interventions, we found that supervisor characteristics (i.e. confidence, knowledge, skills and attitudes) were key mechanisms triggering positive outcomes for short-duration interventions, whereas facilitator characteristics were key mechanisms triggering either positive or negative out- comes for extended-duration interventions. In summary, our findings are novel in two key ways: (1) that short and extended- duration interventions have numerous positive outcomes through mixed pedagogical approaches, social learning, and protected time for supervisors; and (2) that interventions of different durations may work in slightly different ways, with the success of short inter - ventions relying on supervisor characteristics, and extended-duration interventions instead relying on facilitator characteristics. Comparison with existing literature That mixed pedagogies involving active and/or experiential learning were important for the success of supervision training interventions is consistent with educational theories e.g. reflective practice (Schön 1987), experiential learning (Kolb 1984), plus our IPT based on three non-realist reviews of supervision training (Milne et  al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Furthermore, that social relationships were also impor- tant for positive supervision training program outcomes in our modified program theories is also consistent with social learning theories (Shulman 1991, 1993, 2005; Proctor and Inskipp 2001). Finally, that negative outcomes occurred when supervisors were provided with insufficient protected time for learning, is consistent with literature emphasising the tensions between training and service delivery (Sholl et al. 2017). However, the findings of our realist synthesis not only extend our IPT but also add considerable new knowledge to the supervision training literature (Milne et al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Fig. 4 Modified program theory—extended duration intervention 1 3 Supervision training in healthcare: a realist synthesis 555 Firstly, our findings illustrate a wider range of outcomes (including negative outcomes) than has been previously identified in the supervision training literature including our IPT (Milne et al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011). Furthermore, aligned with our IPT based on previous non-realist reviews (Milne et  al. 2011; Gonsalvez and Milne 2010; Tsutsumi 2011), we expected extended-duration interventions to have enhanced pos- itive outcomes compared with short interventions, but we did not find this to be the case based on our realist synthesis of 29 outputs. It is worth noting that our synthesis included nineteen short and ten extended-duration studies from which to draw our conclusions, con- sistent with previous literature suggesting that short-duration supervision training interven- tions were more commonly delivered (Gonsalvez and Milne 2010). We did not identify additional positive outcomes for extended-duration interventions, plus we identified fewer demi-regularities across our identified CMOCs for extended-duration interventions. While this may reflect the fewer outputs reviewed in our study employing extended durations, our findings may reflect a genuine lack of added benefit from extending the duration of supervision training interventions. Indeed, healthcare workers may only require short inter- ventions in order to realize key positive outcomes from training (as long as those short interventions include mixed pedagogies, social learning, protected time, and supervisor characteristics like confidence). Secondly, our findings provide novel insights into the causal pathways for the multi- plicity of ways in which both short and extended-duration supervision training interven- tions work (or not). Indeed, our realist lens has enabled us to identify the multiplicity of mechanisms triggered within supervision training interventions, leading to various positive supervisor outcomes. While interventions of any duration seemed to work through mixed pedagogies, social relationships and protected time (consistent with previous research and educational theories as described above), short interventions seemed to work through supervisor characteristics, whereas extended-duration interventions seemed to work (or not) based on facilitator characteristics. That learner characteristics seemed central in the face of short interventions mirrors previous research flagging the importance of supervi- sors’ personal qualities and skills as key contributors to supervision effectiveness (Wearne et  al. 2012; Gibson et al. 2018), plus learning theories associated with the short-duration interventions, which were exclusively individualist and constructivist in nature such as adult learning theories (Knowles 1990), experiential learning (Kolb 1984) and the nov- ice-to-expert model (Benner 1982). That extended-duration interventions seemed depend- ent on facilitator characteristics, probably relates to the increased importance of facilita- tor–supervisor relationships in the face of enduring associations (sometimes several years long). This also mirrors our finding that extended-duration interventions were associated with middle-range social educational theories. Methodological strengths and challenges Our synthesis was strengthened through the use of a large multidisciplinary team and a rig- orous process aligned with the RAMESES guidelines (Wong et al. 2013, 2017). However, we acknowledge several potential challenges concerning this synthesis. First, although we worked closely with a medical librarian and piloted our search terms, due to the volu- minous nature of the supervision training literature, plus the extensive range of contexts included in our searches, we recognize that we inevitably omitted terms associated with supervision and/or training (e.g. coaching, facilitation etc.) (Lee et  al. 2019). Therefore, we may not have identified all potentially key studies. Second, although our search strategy 1 3 556 C. E. Rees et al. and inclusion criteria did include human services, this literature was either absent or excluded because of its poor quality and/or low realist relevance, meaning that our findings speak to health rather than human services contexts. Third, while we decided to include only peer-reviewed outputs due to the vast supervision training literature, we acknowl- edge that we may have excluded potentially important non-peer-reviewed grey literature, which may have been beneficial in the development of our program theories, and could have accounted for human services contexts. Fourth, none of the outputs included in our synthesis employed realist evaluation methods and as such, we struggled to tease out how context influenced the program theories. Fifth, like others who have identified a lack of evidence pertaining to the outcomes of supervision training on supervisees (e.g. students) and healthcare consumers (Gibson et  al. 2018), the outcomes of studies included in our synthesis are somewhat limited to supervisor outcomes (and often based on self-report). Finally, the papers included in our realist synthesis often lacked explicit articulation of middle-range educational theories on which to base the development and refinement of our program theory. Furthermore, when theories were drawn on they were typically older indi- vidualist theories, rather than more sophisticated contemporary social educational theories. Implications for further research Our study findings and our methodological challenges have a number of implications for further research. Firstly, given that our realist synthesis focuses primarily on health con- texts, further literature reviews are now needed to explore supervision training in human services, perhaps employing different types of review (e.g. narrative review) to describe the types and outcomes of supervision training interventions for human services workers. Secondly, given that our realist synthesis has presented somewhat contradictory and unex- pected findings about intervention duration, further research is now needed to explore more fully the similarities and differences between short and extended-duration supervision training interventions in terms of how they work (or do not work), for whom and under what circumstances, plus drawing on more contemporary social educational theories. The next stage of our supervision training study will employ realist evaluation (Wong et  al. 2012), in order to explore the outcomes of short (i.e. half-day workshops) and extended- duration supervision training interventions for health and human services workers (i.e. half-day workshops plus 3-month longitudinal audio diaries), their underlying mechanisms and associated contextual nuances. Indeed, through employing realist evaluation we hope to better tease out how contextual variations influence mechanisms generating outcomes. Thirdly, similar to others reporting limitations in how the effectiveness of supervision training has traditionally been measured (Milne et al. 2011), further research is now needed that extends the ‘measurement’ of outcomes beyond supervisor outcomes to include out- comes for supervisees, and healthcare consumers. Indeed, realist evaluation could help to flesh out the multiplicity of outcomes for supervisors, supervisees and healthcare consum- ers, as well as identifying the multiple causal pathways. Implications for educational practice Investment in supervision training has been proposed as having greater positive impact than resourcing supervision alone (Hill et  al. 2014). In the quest to develop healthcare workers’ supervisory practices, we have found that supervisor training interventions of any duration can work to enhance supervisors’ confidence, knowledge, skills, and engagement 1 3 Supervision training in healthcare: a realist synthesis 557 through mixed pedagogical approaches involving active and/or experiential learning, privileging social relationships, and protected time. Supervision training that extends over longer periods of time showed no evidence of additional benefits in our realist synthesis. Our review therefore implies that only a modest investment may be required to produce significant outcomes for supervisory practices. These findings are important for resource- sensitive healthcare systems that fund the supervision training of healthcare workers. If offering short-term duration interventions, supervisor characteristics become important mechanisms triggering positive outcomes, whereas facilitator characteristics become cen- tral mechanisms triggering outcomes for extended-duration interventions. Therefore, we encourage healthcare educators involved in the design and facilitation of supervision train- ing interventions to pay close attention to the key mechanisms highlighted in this realist synthesis in order to maximise the positive outcomes of supervision training interventions for supervisors. Finally, from an organizational perspective, supervision training programs need to be situated within organizational workplace cultures that enable supervisors to apply their new-found supervisory knowledge and skills to supervisory practices. Ulti- mately, healthcare organisations need to operate as positive learning organisations in order to maximise supervisory outcomes from training programs. Acknowledgements We would like to thank Anne Young, Medicine, Nursing and Health Sciences Librar- ian from the Hargrave-Andrew Library, Monash University, for her invaluable assistance in the develop- ment of our search strategies and the conduct of those strategies. We would also like to thank Kat Orgallo, Graphic Designer, Teaching Resources Support Unit (TRSU), Faculty of Medicine, Nursing and Health Sci- ences, Monash University, for her help in designing our initial and modified program theory figures. Author’s contributions All authors except EH contributed to the development of the protocol. All authors except EH contributed to clarifying the scope of the synthesis. SLL led the conduct of the searches with feedback from all other authors except EH. All authors except EH participated in the initial study selec- tion based on titles and abstracts involving the relevance of outputs. All authors participated in assessing the rigour and realist relevance of full-text outputs. All authors except VE and BW extracted data from the included studies (with the bulk of this data extraction being conducted by EH). CER led the synthesis stage with input from SLL, EH and CP, and feedback from remaining authors. CER led the write-up of the paper, with input from SLL (methods) and CP (discussion), and feedback and editing from all remaining authors. All authors approve the final version of the paper. CER is principal investigator and acts as guarantor for the paper. 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Affiliations 1 1 1 1,2 Charlotte E. Rees  · Sarah L. Lee  · Eve Huang  · Charlotte Denniston  · 1 3 4 4 5 Vicki Edouard  · Kirsty Pope  · Keith Sutton  · Susan Waller  · Bernadette Ward  · Claire Palermo Monash Centre for Scholarship in Health Education (MCSHE), Monash University, 27 Rainforest Walk (Building 15), Clayton Campus, Clayton, VIC 3800, Australia Department of Medical Education, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, Australia Monash Rural Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Warragul, VIC, Australia Monash Rural Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Bendigo, VIC, Australia 1 3

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Advances in Health Sciences EducationSpringer Journals

Published: Aug 5, 2020

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