• Dominique Piquette, Maria Mylopoulos, and Vicki R LeBlanc.
• Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Wilson Centre for Research in Education, Toronto, Ontario, Canada.
• Med Educ. 2014 Aug 1;48(8):820-30.

ContextCloser clinical supervision has been increasingly promoted to improve patient care. However, the continuous bedside presence of supervisors may threaten the model of progressive independence traditionally associated with effective clinical training. Studies have shown favourable effects of closer supervision on trainees' learning, but have not paid specific attention to the learning processes involved.MethodsWe conducted a simulation-based study to explore the learning opportunities created during simulated resuscitation scenarios under different levels of supervision. Fifty-three residents completed a supervised scenario. Residents were randomised to one of three levels of supervision: telephone (distant); in-person after telephone consultation (immediately available), and in-person from the beginning of the simulation (direct). These interactions were converted into 234 pages of transcripts for analysis. We performed an inductive thematic analysis followed by a deductive analysis using situated learning theory as a theoretical framework.ResultsLearning opportunities created during simulated scenarios were identified as belonging to either of two categories, incidental and engineered opportunities. The themes resulting from this framework contributed to our understanding of trainees' contributions to patient care, supervisors' influences on patient care, and trainee-supervisor interactions. All forms of supervision offered trainees incidental opportunities for practice, although the nature of these contributions could be affected by the bedside presence of supervisors. Supervisors' involvement in patient care by telephone and in person was associated with a shift of responsibility for patient care, but represented, respectively, engineered and incidental opportunities for observation. In-person supervisor-trainee interactions added value to observation and created additional opportunities for incidental feedback and engineered practice.ConclusionsThe shift of responsibility for patient care occurred during both direct and distant supervision, and did not necessarily translate into a lack of opportunities for trainee participation and practice.© 2014 John Wiley & Sons Ltd.

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