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Abstract

Background

Clinical supervision involves the professional relationship between an experienced and knowledgeable clinician and a less experienced clinician in which the experienced clinician provides support toward the skills development of the less experienced one. The concept, structure, and format of clinical supervision vary in various jurisdictions and is influenced by the availability of resources, the training needs of supervisees, and organizational structures.

Aim

The aim of this scoping review was to explore, map out and synthesize the available literature on the facilitators and barriers to clinical supervision in Ghana.

Methods

The methodological framework developed by Arksey and O’Malley and modified by Levac et al. for scoping reviews, and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews were used to ensure a coherent and transparent reporting of literature. A systematic search was conducted in PubMed, CINAHL, Scopus, Medline, and Google Scholar using key words and key terms. Articles published between January 1, 2000, and February 28, 2023, were included in the review.

Results

The initial search across all the databases yielded 208 results. Two independent reviewers completed both the title and abstract, and full text screenings. A third reviewer helped to resolve all discrepancies that arose during the screening process. The review included 20 articles and generated four themes: clinical supervision as a collaborative effort, feedback mechanism, training and adaptation, and challenges with implementation.

Conclusion

Findings from this review highlight that healthcare professionals in Ghana valued clinical supervision. However, the implementation of clinical supervision is faced with individual and systemic challenges. There is the need for on-going collaboration between educational and clinical institutions to develop modalities that promote clinical supervision in Ghana.

Keywords

clinical supervision clinical practicum clinical mentoring preceptorship

Introduction

Clinical supervision is a crucial component of the professional development of healthcare professionals. It is a process that provides a safe, supportive, and reflective environment for new and trainee healthcare providers to discuss their clinical work and receive feedback from a more experienced colleague. Clinical supervision aims to enhance the quality of patient care by supporting healthcare providers to improve their knowledge, skills, and confidence. Generally, clinical supervision is seen as complementary to, but separate from, managerial supervision, which is about monitoring and appraising the performance of staff (Masamha et al., 2022). Clinical supervision is a formal and disciplined working alliance that is generally, but not necessarily, between a more experienced and a less experienced clinician or trainee, in which the supervisee's clinical work is reviewed and reflected upon, with the aims of improving the supervisee's work with clients; ensuring client welfare; supporting the supervisee's work and supporting the supervisee's professional development (Martin et al., 2021; Rockville, 2009).

The process of clinical supervision has been described differently by different schools of thought (Masamha et al., 2022). However, the merging point for all the concepts is underpinned in the systematization and continuous professional support provided to learning clinicians (Kühne et al., 2019; Tugendrajch et al., 2021). In some professions, alternative titles such as “peer supervision,” “developmental supervision,” “reflective supervision,” or “supervision” are used to explain the professional supervisor-supervisee relationship.

The development of skills by students and junior practitioners in healthcare largely depends on factors existing in the clinical environment and health education institutions. Students are well supported in a well-resourced clinical environment, which ultimately enhances skills acquisition, professional development, and positive health outcomes for clients (Haraldseid et al., 2015; Mbakaya et al., 2020). Globally, clinical supervision remains a significant tool in developing skills and building a resilient workforce. There is ongoing research to develop more holistic approaches to clinical supervision in contemporary healthcare. However, research output and their application are mainly concentrated in high-income countries and designed to meet the specific needs of these countries (Yegros-Yegros et al., 2020).

Contextually, healthcare education and training vary among countries (Adams et al., 2016), and while globalization in healthcare is gaining enormous grounds, Kruk et al. (2018) suggests that healthcare policies should be tailored toward specific needs of individual countries. In Ghana, clinical supervision is a vital component of the healthcare system, with the various professional bodies making significant investments in developing and implementing supervisory policies and guidelines. Despite these efforts, the evidence on clinical supervision remains scattered. The aim of this scoping review is to explore, map out and synthesize the existing literature on the facilitators and barriers to clinical supervision in Ghana. Findings from this review will help to identify key issues and facilitators of clinical supervision, and to inform healthcare policies and practices related to clinical supervision in Ghana.

Methodology

The review followed the Arksey and O’Malley (2005) framework for scoping reviews with the suggestions and modifications by Levac et al. (2010). A scoping review enhances a detailed and extensive exploration and mapping of the available literature on the study phenomena (Mak & Thomas, 2022). In particular, the aim of this scoping review was to explore, map out and synthesize the available literature on the facilitators and barriers to clinical supervision in Ghana. Studies of diverse methodological approaches (quantitative, qualitative, and mixed method) were included in the review. A search was conducted for grey literature from government and university databases. The researchers used an iterative process that included identification of the review question, identification of relevant literature, selection of relevant studies, charting, and collating data, and summarizing and reporting findings. The review identified similarities and dissimilarities in the included studies, mapped key findings and developed themes. Findings were presented using a narrative synthesis approach (Cruzes et al., 2015). The researchers followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to ensure a coherent and transparent reporting of literature (Tricco et al., 2018).

Identifying the Research Question

The researchers formulated a broad research question using the Population, Concept and Context (PCC) framework. The research question was “what is the existing body of literature on the barriers and facilitators to clinical supervision in Ghana?”

Population: Healthcare workers and trainees

Concept: Clinical supervision (Synonymous to preceptorship)

Context: Healthcare settings including hospitals, clinics, Community Health, and Planning Services (CHPS compounds) and training institutions in Ghana.

Identifying Relevant Studies

The researchers conducted an initial search in PubMed, Cochrane Library for Systematic Reviews, and Prospero to ensure that similar studies have not been conducted or registered as an ongoing project. After confirming the novelty of the topic, a comprehensive search in electronic databases including PubMed, CINAHL, Scopus, Medline, and Google Scholar were conducted. The researchers collaboratively developed an iterative search strategy and systematically searched the identified databases using keywords, Medical Subject Heading (MeSH) terms, truncation, and wildcards in March 2023. Boolean operators “OR” and “AND” were used to supplement the search in databases to locate literature that is relevant to the research objectives. Search terms such as “Clinical” OR “Hospital” OR “Healthcare” AND “Supervision” OR “Preceptorship” OR “Mentorship” AND “Ghana” were used across databases to search for literature. The search was extended to Ghanaian universities’ research repository and identified studies that potentially met the inclusion criteria.

Study Selection and Inclusion

Two authors independently screened the titles and abstracts of the identified studies to determine their eligibility for inclusion. All the identified articles were stored in Zotero (Vanhecke, 2008), a reference management software. Full-text articles were obtained for studies that met the inclusion criteria, and two reviewers independently assessed them for eligibility. Any disagreements were resolved through discussion, and consultation with a third reviewer. The reference lists of the included articles were searched to identify potential articles for inclusion. The researchers included all published and grey literature that explored or discussed clinical supervision among health care workers and trainees in Ghana. The broader range of health care disciplines were included in the scoping review to gain insight from related fields such as nursing, medicine, allied health professions, and social sciences. Articles published between January 2000 and February 2023 were included. Only articles published in the English language were included in the review. The review excluded studies that focused on other countries other than Ghana, studies that were conducted before the year 2000 and studies that were not written in English. The study selection process is presented in Figure 1.

Figure 1.

PRISMA flow diagram for study selection process (Moher et al., 2009).

Charting the Data

Data extraction and charting was performed by two reviewers using a standardized form developed and pre-approved by all the authors. The form included the following information: Author and year of publication, study design, location of study, study population, objectives of the studies, and the main findings. The extracted data was stored in a spreadsheet and presented in Table 1.

Table 1.

Data extraction form for included studies.

Authors/year	Study design	Geographical location	Population/sample size	Research objective(s)	Main finding
Abuosi et al. (2022)	Cross-sectional study	Upper East Region	254 Third-year nursing and midwifery students	To assess trainees’ perceptions of the number of students on the ward or clinical unit, and the quality of the clinical learning environment	Number of students on the ward had an impact on the quality rating of students’ experience. The leadership style of preceptors influenced the student's experience. Quality of clinical learning was affected by too many students with few preceptors and clinical equipment for practice
Achempim-Ansong et al. (2022)	Aesthetic phenomenological approach	Greater Accra region	Supervisors (18) and Supervisees (12)	To explore the benefits and challenges of administrative clinical supervision at the unit	Benefits include reduction in infection rates, improved competence, client satisfaction, reduction in negligence, efficiency, accountability, and feeling of being appreciated. Challenges were managerial, limited time, interpersonal conflict with colleagues, and increased workload.
Adjei et al. (2018)	Exploratory descriptive phenomenological design	Greater Accra region	33 Nursing Students	To document the perception and challenges that students face during intra-semester clinical placement	Students perceived intra-semester practicum to be beneficial to their learning. Inadequate support from staff. Poor staff-student relationship affecting skills acquisition. Theory-Practice gap associated with under-resourced practice learning environment. Students assigned to do menial jobs. Students also reported stress, limited period spent on practicum
Alhassan et al. (2022)	Quantitative descriptive cross-sectional study	Northern Ghana	172 Preceptors	To explore the perceptions of preceptors regarding the support they receive in the preceptorship role, their commitment to the role, and the incentives that are important to them.	Support was higher among co-workers than nursing managers. Training and availability of learning resources were the most rated incentives. Participants perceived themselves to be highly committed to the role. Participant's demographics did not have influence on their perceived commitment.
Amoo et al., (2022)	Qualitative exploratory, descriptive design	Nationwide study	16 Final year Nursing Students	Describe the factors that promote clinical teaching. Examine students’ perceptions of clinical teaching. Describe the impact of clinical learning on students. Explore ways of improving clinical teaching and learning	Factors that promote clinical teaching and learning include supervision, teaching, and facilitation of student's independence. Participants thought supervision, teaching and autonomy were important to their clinical learning. The Clinical learning environment facilitated skills acquisition. Challenges include poor attitudes of both students and practitioners, lack of resources to support experiential learning and unavailability of clinical supervisors
Asare (2017)	Cross-sectional survey	Greater Accra Region	24 Final year radiography students	To investigate final year undergraduate radiography students’ perceptions of clinical placements, in relation to the clinical learning environment (CLE) and their learning achievements	Participants thought the feedback and opportunities for seminars were insufficient. The participants were satisfied with the support they received from supervising radiologists. Opportunity to integrate theory into clinical practice and the development of patient-centered care and clinical competence was highly rated.
Aryere (2018)	Mixed method (qualitative and quantitative)	Greater Accra Region	200 Nursing and Midwifery students Nursing Tutors Clinical supervisors	To examine the factors that influence the quality of clinical supervision among nursing and midwifery students at the 37 Military Hospital	Quality of supervision was rated below average. Factors identified as influencing clinical supervision were pre-clinical student orientation, lack of training for supervisors, negative attitude of clinical staff, sexual harassment, absence of a standard guideline for student clinical supervision, lack of tutor visit to the CLE, emotional stress during clinical practice, inadequate logistics for students to work with, time constraints and heavy workload schedules for tutor supervisors. Personal attributes of students including marital status, program of study, closeness to the clinical learning environment and their input on placement sites had an effect on the quality of supervision.
Asirifi et al. (2017)	Focused ethnographic approach.	Nationwide	Nurse educators (8), Nursing students (9), and Preceptors (9)	To identify the challenges affecting the triad during placement. To describe the role of students, preceptors, and nurse educators during preceptorship.	Preceptors were role models, evaluators, and liaison between the nursing schools and clinical settings. Nursing educators support students and preceptors. Nursing students were required to ask questions and commit to learning. Inadequate preceptor support, lack of equipment for clinical teaching and learning, and discrepancies during the process of evaluating students’ performances were challenges to the implementation of preceptorship in Ghana.
Asirifi et al. (2013)	Focused ethnographic approach.	Nationwide	Nurse educators (8), Nursing students (9), and Preceptors (9)	To explore the perceptions of Ghanaian nursing students, preceptors, and nurse educators regarding their preceptorship experience.	Preceptorship is informally integrated in nursing education in Ghana. Preceptors are not adequately prepared, supported and incentivized for the role. Lack of coordination between clinical learning environment and HEIs. High workload: 1 preceptor to more than 5 students.
Atakro et al. (2019)	Qualitative exploratory descriptive design	Greater Accra and Ashanti Regions	79 Undergraduate Nursing students	To explore the experiences of undergraduate nursing students in selected teaching hospitals in Ghana	Feeling isolated in clinical placement. Inadequate application of the nursing process. Encounter with complex medical devices and conditions. Inadequate application of physical examination by nurses.
Atakro (2017)	Exploratory qualitative design	Volta region	30 Student Nurses and Midwives	To explore the experiences of student nurses and midwives in clinical placement	Nursing and midwifery practice is honorable but a sacrifice. Missed objectives and expectations during clinical placements. Experiences of fears and anxieties before and during clinical placement. Poor interpersonal relations between students and staff during clinical placement
Bellerose et al. (2021)	Mixed method	Greater Accra and Volta Regions	197 Community Health Nurses (CHN)	To explore the content and frequency of community health nurses in Greater Accra and Volta regions.	Supervision is directly related to job outcome. CHNs were not satisfied with the type of supervision they received.
Ebu-Enyan et al. (2021a)	Descriptive phenomenology	Central Region	22 Nursing Preceptors	To explore the lived experiences of preceptorship of student nurses and the challenges confronting the preceptorship role	Preceptors find supporting students satisfying. Poor attitudes of students towards learning worrisome. The need to frequently improvise for practice learning equipment impedes students’ support. Too many students to one preceptor. Schools need to partner with placement facilities for efficient student supervision. Frequent meetings and feedback needed for students’ development.
Ebu-Enyan et al. (2021b)	Descriptive cross-sectional	Central Region	442 Nurses and Midwives	Empirical study to explain the relationship between some of the identified motivators and practitioners’ intention to act as preceptors soon.	Majority of participants did not have training for preceptorship (91.9%). Desire to precept in the future high (88.2%). The desire to support nursing students to develop their clinical skills was the most important motivating factor. Participants thought in-service training in preceptorship could facilitate effective perception. Lack of training and preparedness. High Workload. Inadequate support from Higher Education Institutions (HEIs) and line managers.
Kobekyaa and Naidoo (2023)	Qualitative descriptive, exploratory.	Northern Region	Nurse educators (16) Clinical preceptors (10) Nursing (10) and Midwifery (10) students	To describe the experiences of collaborative clinical facilitation among nurse educators, clinical preceptors and final year nursing and midwifery students	Team-based mentorship and supervision, personalized preceptorship and clinical conferences fostered clinical learning. Challenges were staff shortages and lack of timely communication.
Mensah et al. (2021)	Focused Ethnography design	Ashanti Region	12 Nursing and Midwifery students	To explore students’ views and stories about their clinical practicum experiences and to help gain a deeper understanding into their knowledge, competency acquisition, clinical learning, and transition to practice.	Least supported to acquire the necessary clinical skills and competencies. Lack of preceptors and limited preparedness of ward nurses to support students. Needles errands resulting in missed practical learning opportunities. Practice-Theory confusion due to lack of collaboration between tutors and clinical supervisors during clinical placement
Antwi & Kyei, 2015	Quantitative descriptive study	Nationwide	42 Undergraduate student Radiographers	To identify factors that contribute to a positive clinical experience. To evaluate students’ clinical supervision, evaluation, confidence, and assessment as carried out during clinical placement. To identify areas of strengths and/or limitations of clinical placement venues	Inadequate feedback by supervisors were identified by participants as barriers to the clinical learning environment. Participants indicated adequate knowledge and valued the clinical placement period. Learning outcomes were largely achieved, majority learnt by active experimentation.
Nachinab and Armstrong (2022)	Cross-sectional survey	Northern Ghana	319 Nursing Preceptors	To assess preceptors’ perception of the quality of clinical nursing education	Preceptors generally perceived the quality of clinical nursing education to be just above average. Clinical preceptorship is a shared responsibility.
Nsemo et al. (2022)	Descriptive survey	Eastern and Ashanti Regions	269 Midwifery students	To investigate student midwives’ knowledge and perception of the roles of preceptors during clinical practice	Preceptorship might be a new concept in midwifery education, it is a module that is known to most students and is perceived as an integral part of their training.
Ziba et al. (2021)	Cross-sectional survey	Northern Region	225 Nursing and Midwifery students	To assess students’ evaluation of the clinical learning environment and the factors that influence their learning experience.	Student supervision was either by private or team supervision. Private supervision was more likely to be rated satisfactorily and achieve better student clinical experience compared to team supervision. Nursing students were more likely to have better clinical experience compared to their midwifery counterparts.

Collating, Summarizing, and Reporting the Results

Study Characteristics

The review identified 203 articles across all databases and 5 articles from gray literature sources. A total of 85 duplicate articles were removed via Zotero referencing manager leaving 123 articles for further screening. After abstract and title screening, and full text screening, 20 records met the inclusion criteria and were included in the study. A search of the reference lists of the included studies was conducted, and no additional articles met the inclusion criteria. The researchers therefore did not include any studies from the reference lists.

The included studies utilized diverse methodological approaches (quantitative, qualitative, and mixed methods). Half (50%) of the studies were qualitative in nature, quantitative (40%), and mixed methods (10%). The studies were conducted across the northern, central, and southern belts of Ghana. Almost all the studies (90%) were nursing, and midwifery related, and 10% were conducted among student radiographers. Only 5% of the studies focused on supervision of junior healthcare workers in practice, with the rest 95% focusing on students’ supervision. Four main themes were identified in the included studies. They include supervision as a collaborative effort, training and adaptation, challenges of implementation, and feedback mechanism.

Themes

Clinical Supervision as a Collaborative Effort

The collaborative nature of clinical supervision in Ghana is multifaceted and involves the partnership between educational institutions and clinical settings, and the supervisor and supervisees (Alhassan et al., 2022; Asirifi et al., 2013; Ebu-Enyan et al., 2021a; Mensah et al., 2021; Nachinab & Armstrong, 2022). Overcrowding of students and excessive workload has been identified as a hindrance to positive outcomes of clinical supervision (Nachinab & Armstrong, 2022). As noted by a study participant in Nachinab and Armstrong (2022, p.4):

There is no space and when the students come they are usually also a lot. Sometimes the students that come are more than the number of patients plus the staffs in the ward. You can have 15 students for one shift.

Health training institutions can work together and streamline the number of students on clinical placements in healthcare facilities at specific times. The collaboration between educational institutions and the clinical settings will help to bridge the gap between theory and practice (Mensah et al., 2021; Nachinab & Armstrong, 2022), as well as facilitate quality learning environment for the students. For clinical placement objectives to be met, training institutions must provide detailed information regarding students’ placement objectives, as well as having trainers from the classrooms occasionally visiting the clinical settings to monitor students’ progress (Asirifi et al., 2013; Mensah et al., 2021; Nachinab & Armstrong, 2022). By doing so, preceptors can work diligently with students to achieve the specific goals (Ebu-Enyan et al., 2021a). One of the staff from the clinical setting in Nachinab and Armstrong (2022, p.6) noted that “There are certain times the students will come all throughout and we wouldn’t see any lecturer following up from the school.” Similar concerns were acknowledged by a nursing lecturer in the same study who stated “As a school, we don’t have any standard or structured way of even monitoring… there is poor supervision, so you don’t know whether the students are going to the wards or not.”

The cumulative implication is that students’ goals are not being met as they mostly become unsupervised. A participant in Ebu-Enyan et al. (2021a, p.5) believed that “The schools should link up with the hospitals; communicate with the DNS, the nurse in-charge as well as some of the nurses on the ward” to harness support across all spheres to provide adequate clinical supervision to the students. The supervisor and the supervisee also have a shared responsibility that is built on trust, honesty, openness, and respect to achieve certain goals. The roles of both parties in this partnership must be clearly defined. Although the role of the clinical supervisor has been deemed challenging (Alhassan et al., 2022; Asirifi et al., 2021; Ebu-Enyan et al., 2021a), there is often a relief among supervisors seeing their students graduate and join the profession as noted by a participant in Ebu-Enyan et al. (2021a, p.3):“Seeing my students doing well, coming out successfully as professional nurses and…they also putting up their best in their work give me that joy to keep on training them to assist in the work that we are doing.”

Challenges of Implementation

Challenges accounting for ineffective implementation of clinical supervision and preceptorship in Ghana can be attributed to several factors including those related to the supervisor and the supervisee, educational institutions, and the management of the clinical setting (Abuosi et al., 2022; Achempim-Ansong et al., 2021; Adjei et al., 2018; Amoo et al., 2022; Aryere, 2018; Asirifi et al., 2013; Atakro, 2017; Ebu-Enyan et al., 2021b; Kobekyaa & Naidoo, 2023; Mensah et al., 2021). The uncooperative attitude of students toward clinical placement was identified as a factor to poor clinical supervision (Achempim-Ansong et al., 2021; Atakro, 2017; Ebu-Enyan et al., 2021a, 2021b). A research subject in Ebu-Enyan et al. (2021b) noted that: “Some of the challenges are students not obeying instructions given to them; students not coming to work as they are supposed to and also being disrespectful. When you give them instructions and they refuse to go according to the instruction given to them, it gives you a lot of work to do. Sometimes you assign them, and they run away.” In contrast, other studies (Adjei et al., 2018; Amoo et al., 2022; Asirifi et al., 2013; Atakro, 2017; Ebu-Enyan et al., 2021a; Mensah et al., 2021) noted that, clinical supervisors’ unfavorable attitudes were a barrier to achieving good clinical supervision outcomes. Some students bemoaned that they were assigned to carry out tasks outside their scope of practice, including petty tasks that were unrelated to clinical practice. A study participant in Adjei et al. (2018) narrated: “They (nurses) kept on sending me everywhere, I went to the orthopedic unit, and many places. Anytime I return they will say that I have the long legs so I have to be transporting patients to other units. Sometimes, I don’t even get time with the patients. I sometimes spent a maximum of five minutes with my patients the whole day.”

Challenges with the link between theory and practice were noted as a concern by both students and preceptors (Adjei et al., 2018; Amoo et al., 2022; Asirifi et al., 2013; Atakro 2017; Ebu-Enyan et al. 2021b; Mensah et al., 2021). A participant in Amoo et. al., (2022, p.5 ) rated their clinical setting experience as inadequate and had this to say: “Comparing it to what we actually learn at the skills lab, I would say it's not adequate in the sense that we do not actually get the opportunity to practice everything that we’ve learned. What we do will sometimes be dependent on what is happening at the ward.” This can potentially be attributed to the lack of resources in the clinical setting and the workload on the wards (Achempim-Ansong et al., 2021; Amoo et al., 2022; Aryere, 2018; Asirifi et al., 2017; Ebu-Enyan et al., 2021a; Kobekyaa & Naidoo, 2023). A preceptor in Asirifi et al. (2017, p.6) noted that, “the students were willing to work but because of inadequate equipment in the wards it is difficult for them to practice well. The water is always not flowing. So, we are not able to demonstrate decontamination properly for students to see.”

Training and Adaptation

A successful clinical placement requires adequate preparation and readiness of both the preceptor and preceptee (Alhassan et al., 2022; Asirifi et al., 2013; Ebu-Enyan et al., 2021a; Kobekyaa & Naidoo, 2023; Mensah et al., 2021; Nsemo et al., 2022). Although the concept of preceptorship was introduced in Ghana over three decades ago, the preceptor role is yet to be fully recognized and integrated into formal training and clinical practice. Most preceptors have no formal training for the role (Aryere, 2018; Asirifi et al., 2013; Ebu-Enyan et al., 2021a; Nsemo et al., 2022) and tend to provide ad hoc supervision to students. A participant in Asirifi et al. (2013, p.5) remarked “Our preceptorship experience started in 1992 when a group of nurses from the various regions were invited to the School of Nursing, for a workshop on preceptorship. This was done by the Nurses and Midwives’ Council of Ghana in collaboration with the Ministry of Health… The nurses who had that opportunity to attend the workshop were supposed to train other nurses to be preceptors. After the training, we organized a one-week workshop for some nurses in the region. But we could not follow-up from there. Fortunately, the management has put preceptorship down as one of her priority areas so it is in the pipeline; we started but how to solidify it is the issue now.”

Clinical staff who take up preceptorship role need to be adequately trained and supported to develop relevant leadership skills to support junior members (Abuosi et al., 2022; Aryere, 2018; Asirifi et al., 2013 , 2017). A participating student in Asirifi et al. (2013, p.6) believes preceptors need to be frequently trained for the role “preceptors should go through in-service training monthly so that they would be abreast with current trends in teaching students.” Formal recognition of the preceptorship role, support from peers and training are very important motivating factors for staff who engage or intend to participate in mentoring students and junior staff (Alhassan et al., 2022; Ebu-Enyan et al., 2021a). Preceptors expressed feeling unsupported as noted by a preceptor in Asirifi et al. (2013, p.6) “I did not get any official training for the preceptorship program but it is through my length of experience in nursing that I am using in teaching.”

Pre-placement orientation has been identified as an important consideration for a successful clinical supervision and positive students’ experience during clinical placements (Aryere, 2018; Ebu-Enyan et al., 2021a). Pre-placement orientation include the introduction of preceptors and preceptees to the objectives, and expectations of the practice placement prior to the start of placement to ensure that goals are formulated (Adjei et al., 2018; Aryere, 2018; Atakro, 2017; Atakro et al., 2019; Ebu-Enyan et al., 2021a). Furthermore, pre-practice orientation provides the opportunity for role clarification and establishes professional boundaries between preceptors, preceptees and other members of staff (Amoo et al., 20222022; Aryere, 2018). This is particularly important due to the concerns about poor interpersonal relationship between preceptors, preceptees and other members of staff (Atakro, 2017).

The Feedback Mechanism

Feedback and feedforwarding are important for the development of safe and supportive clinical skills (Bellerose et al., 2021; Ebu-Enyan et al., 2021b; Antwi & Kyei 2015). Notwithstanding, feedback must be structured with clear guidelines for setting objectives and expectations. Feedback needs to be timely, sufficient, and collegial taking into cognizance the developmental needs of the supervised (Bellerose et al., 2021; Ebu-Enyan et al., 2021b; Antwi & Kyei, 2015). As noted in Bellerose et al. (2021, p.6), a community health nurse was of the view that, supervisors constantly embark on fault finding mission, and “sometimes when they come, they only come to point at mistakes…and then bombard you with insults…and don’t correct you. They can support us by using appreciative words. It's would motivate us to work by giving us a chance to express ourselves without them becoming defensive…They should show us respect.”

Feedback was noted to be a key factor that boosts confidence and improves job performance of nurses (Atakro, 2017, Asare, 2017;; Bellerose et al., 2021). Asirifi et al. (2017) and Atakro (2017) recommended that feedback should become an official and integral part of clinical supervision. A student on placement recounts that “Most of the time, senior nurses shout at me when I am going wrong in performing a procedure, Staff nurses and midwives insult us when we make mistakes which need correction” (Atakora, 2017, p.5) Again, feedback should be a collaborative learning practice between the preceptor, preceptee and the academic supervisor. This should make room for the preceptee to question their feedback. Students do not often get the opportunity to discuss feedback. A participant in Asirifi et al. (2017, p.6) bemoaned that “I was not always satisfied with it [evaluation] but I had to take it like that. When we asked questions about the evaluation, they [preceptors] told us that as students we were not perfect in performing the nursing procedures yet.” Constructive feedback plays a significant role in improving learners’ motivation and helps them to clearly understand what ought to be done as part of their training program.

Discussion

In Ghana, health care professional regulatory bodies mandate all trainees to undergo supervised practice before entering the appropriate register (Allied Health Professional Council of Ghana, 2023; Medical and Dental Council of Ghana, 2023; Nursing and Midwifery Council of Ghana, 2023). This requirement for supervised practice extends to junior staff, graduates on the temporary register, and trainees. This scoping review explored the concept of clinical supervision among the health care professionals in Ghana to facilitate cross-learning of best practices, ensuring uniform and effective supervision across the diverse healthcare disciplines. Although, the review included clinical supervision among all the healthcare professionals and trainees in Ghana, only a few studies reported supervision among radiographers and the rest were conducted among junior nurses and nursing trainees.

Clinical supervision is an integral part of professional development and quality assurance in healthcare. When facilitated effectively, clinical supervision equips clinicians and promotes positive patient care outcomes (Driscoll et al., 2019). The findings from this review demonstrate that, while both senior and junior clinicians understand the significance of clinical supervision, they are often faced with individual and organizational level challenges.

Clinical supervision has been proven to be most effective when practiced collaboratively (Borders, 2023; Snowdon et al., 2017). As reported in this current review, collaboration in clinical supervision in Ghana is a multifaceted endeavor, requiring partnership between educational institutions, clinical settings, and the supervisor-supervisee relationship. Overcrowding of students and excessive workload were identified as hindrances to positive outcomes, with participants expressing concerns about insufficient space and an imbalance between the number of students and available resources. Supervisors’ workload, overcrowding and limited resources are recurring themes that are continually reported as hindrances to the effectiveness of clinical supervision (Lethale et al., 2019; McLeod et al., 2021).

In most cases supervisors still have full time commitment to patient care at the same time as supervising students resulting in little or no time commitment with students (Lethale et al., 2019). A collaborative effort between educational institutions and clinical settings is therefore important to support supervisors and to bridge the gap between theory and practice, facilitating quality clinical learning environment for students and junior staff (McLeod et al., 2021). This is the case in many Western countries where partnerships between academia and healthcare institutions are considered crucial for effective clinical supervision (McLeod et al., 2021; Pollock et al., 2017). At the institutional level, policy makers and healthcare leadership need to work together to formalize the implementation of clinical supervision policies (Driscoll et al., 2019).

The review also identified an absence of structured monitoring processes as a barrier, leading to unsupervised students and unmet learning goals. The lack of organizational direction and policy can lead to poor implementation and additional workload for the supervisors (Driscoll et al., 2019). There must be clear communication and coordination between schools and hospitals, with detailed information on supervisory objectives and occasional visits by trainers to monitor progress, to ensure adequate clinical supervision.

Furthermore, successful clinical placement necessitates adequate preparation and readiness from both preceptors and preceptees (Anwar et al., 2019; McLeod et al., 2021). Despite the introduction of preceptorship in Ghana three decades ago (Asirifi et al., 2013), the role is yet to be fully recognized and integrated into formal training and clinical practice. Lack of formal training for preceptors, ad hoc supervision, and the absence of ongoing in-service training were notable challenges in this review. Preceptors expressed feeling unsupported, emphasizing the need for formal recognition of the preceptorship role, support from peers, and regular training. The review also identified uncooperative attitudes of students and unfavorable behaviors of clinical supervisors as impediments to achieving positive outcomes. Students reported being assigned tasks outside their scope of practice, affecting their time with patients, and compromising the quality of their clinical experience. Unfavorable behaviors of both the supervisor and supervisees have been reported in the literature as factors that can negatively affect clinical skills acquisition during the supervisory relationship and should therefore be addressed (Donough & Van der Heever, 2018; Lazar & Eisikovits, 2008).

Clinical supervision is a skill that requires both clinical and interpersonal skills. Although clinicians and junior staff must take responsibility for self-development to meet the requirement for their practice, organizations need to provide opportunities for clinicians to undertake continuous professional development courses that include learning to supervise in the clinical setting. The lack of adequate preparation has been reported elsewhere (Reynolds & McLean, 2023; Rothwell et al., 2021) and has been linked to experienced clinicians’ unwillingness to supervise their subordinates. The lack of adequate preparation often translates into increased workload for the supervisor (Banda et al., 2022; Kovacs & Lagarde, 2022), and leads to decreased attention to the supervision process.

Feedback in clinical supervision has been described as a double-edged sword; a process that enhances learning and professional development. Supervisors receive feedback from their mentees to evaluate their own performance while the novice clinician is guided to improve their performance (Hardavella et al., 2017). However, feedback about clinical supervision often tends to over emphasize weaknesses and potentially neglect the strengths and achievements of the supervised (van Woerkom & Kroon, 2020). As reported by Weallans et al. (2022) and Snowdon et al. (2017), and confirmed in this review, feedback in clinical supervision sometimes presents the subjective opinions of supervisors, with a little focus on the novice clinician's experiences. This may present as a distinct source of stress for junior clinicians. To maximize the benefits of the feedback process in clinical supervision, it is important to ensure that feedback is constructively delivered, with a focus on growth and improvement through fairness and objectivity.

Limitations

This scoping review acknowledges some limitations. First, the review only identified studies that focused on nursing, with limited representation from radiographers and none in the other healthcare disciplines. This introduces a potential bias. Additionally, the restriction to English-language publications may have excluded valuable insights from non-English sources and the timeframe limitation may have omitted earlier relevant publications. Finally, potential publication bias and the reliance on available literature, may have affected a comprehensive capture of the nuances of clinical supervision practices across all healthcare disciplines in Ghana. Therefore, the review's generalization is therefore constrained by these limitations.

Conclusion

This current review has highlighted the scope of clinical supervision in Ghana. Evidence from this review indicates that there is ongoing research, especially in nursing and midwifery training and practices on clinical supervision. Nonetheless, findings from these studies appear to be less implemented as studies conducted over the years have reported similar outcomes regarding the need for stakeholder collaboration for a better policy outcome. The barriers and facilitators of clinical supervision appear to be multidimensional and require ongoing interprofessional research and healthcare policy direction.

Implication for Practice

This review contributes to the ongoing research and discussion surrounding clinical supervision in low and middle-income countries. It is crucial to recognize that clinical supervision is an essential skill that every healthcare professional must cultivate. Given the importance of this skill, healthcare professionals should view supervision as a lifelong learning journey. As healthcare continues to evolve and the demand for healthcare services increases, clinical supervision becomes a key aspect that can enhance the competence of new and trainee professionals. Therefore, it is imperative to foster collaboration in the development and implementation of clinical supervision strategies. Policy makers must work closely with industry players to develop modalities that reflect the needs of junior and senior health practitioners. Clinical supervision should be integrated into the training curriculum of healthcare professionals to enable them to understand the key concepts and the necessity to participate in clinical supervision. Leaders in healthcare must take genuine interest in the professional and skills development of professionals to equip them adequately to participate in developing strategies at the local level towards effective clinical supervision.

Footnotes

Author Contributions

S.K. Awiagah contributed to conceptualization, project administration, data curation, formal analysis, writing, editing, review, methodology, and project validation. R. Dordunu contributed to data curation, formal analysis, writing of draft, formal analysis, review, editing, and project validation. N. Hukporti contributed to conceptualization, visualization, writing of draft manuscript, review, editing, and project validation. P.E. Nukunu contributed to conceptualization, visualization, writing and editing of manuscript, data curation, formal analysis, and project validation. G. Dzando contributed to conceptualization, supervision, methodology, data curation, formal analysis, validation, writing, review, and editing.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval

No human subjects were involved in the study; therefore, no ethical approval is required.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sherrif Kwame Awiagah

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Barriers and Facilitators to Clinical Supervision in Ghana: A Scoping Review

Abstract

Background

Aim

Methods

Results

Conclusion

Keywords

Introduction

Methodology

Identifying the Research Question

Identifying Relevant Studies

Study Selection and Inclusion

Charting the Data

Collating, Summarizing, and Reporting the Results

Study Characteristics

Themes

Clinical Supervision as a Collaborative Effort

Challenges of Implementation

Training and Adaptation

The Feedback Mechanism

Discussion

Limitations

Conclusion

Implication for Practice

Footnotes

Author Contributions

Declaration of Conflicting Interests

Ethical Approval

Funding

ORCID iD

References