Supporting health professional educators in the workplace: A scoping review

Abstract Purpose Clinical educators frequently request additional support for educating pre-qualification health professions students despite having access to professional development programs to build education knowledge and skills. The breadth of ‘additional support’ options remains unclear. The aim of this review is to explore what is known about support options for health professional educators in the workplace through the lens of learning organisations. Materials and methods A scoping review was conducted searching Ovid Medline, CINAHL, ProQuest and PsycINFO electronic databases from 1 January 2005 up to 21 October 2020 for studies that identified support strategies for clinical educators of pre-qualification students in the workplace. Relevant data were charted, summarised thematically and synthesised with reference to support type and implementation level. Results Fifty relevant records related to medicine, nursing and allied health clinical education were included. Twelve support themes and five cross-cutting support categories were identified across four implementation levels of healthcare systems. Conclusions A diversity of support for clinical educators beyond professional development was identified. Future research combined with leadership and commitment from the healthcare and education sectors is needed to better understand the applicability, efficacy and resourcing of any newly integrated support to ensure it is sustainable and improves clinical educator capability.


Introduction
Training the next generation of health professionals is essential for workforce sustainability. Responsibility for teaching and clinical education of students in health services is traditionally assigned to senior staff or, 'clinical educators' (Rodger et al. 2008), with a recognised productivity impact (Department of Health 2021). Clinical educators are purportedly prepared for this role through education programs that build knowledge and skills (Steinert et al. 2006). However, little is known about what other support types may drive educator capability in healthcare services. Understanding supports that may supplement staff development programs could assist strategic planning in healthcare organisations. In this review, support was defined as an action or mechanism enabling clinicians to improve or engage in their clinical educator role.
Health professional student education occurs within a complex and dynamic healthcare system. Organisational learning, as described by Bohmer and Edmondson (2001), is the process of improving organisational actions through the consideration of multiple dynamic levels of action, rather than a focus on linear change at the individual level. Organisational learning provides a useful conceptual lens to explore how educators may be supported beyond the level of the individual clinician, to consider support at the unit/ team, organisation and system level. University-affiliated healthcare organisations engage in agreements with healthcare providers to train pre-qualification health professions students. Ideally, everyone in a healthcare facility would share the facility's commitment to training students, accepting students as a part of the team rather than a burden, however, this may not occur. Given values are inextricably linked to behaviour (Day and Leggat 2015), a lack of congruence between the organisation's espoused and enacted education values can result in cultural challenges or resource limitations that leave clinical educators feeling unsupported or incapable of fulfilling their education responsibilities. Organisational culture reflects enacted values, as such, learning organisations are best placed to be innovative and support education delivery (Davies and Nutley 2000).

Practice points
Clinical educators frequently request more support to assist them in their education role within health services. Categories of support may be practical, relationships, advocacy, capability or knowledge. Supports for clinical educators operate at the individual, unit, organisation or system level. Clinical education within healthcare requires advocacy and leadership for recognition as an essential activity at all levels. Implementation of additional supports for clinical educators must be appropriately resourced and pervasive within and across organisations.
Demand for student education in health services continues to grow. In Australia, the removal of caps on university places to manage workforce shortages (Department of Health and Human Services 2016) increased registered health students by 64% between 2012 and 2019 (AHPRA 2012(AHPRA , 2019. Profession placement planning and delivery differ, but generally, demand for placements is without proportionate increases in resource allocation to deliver high-quality placements whilst maintaining clinical service provision (Bowles et al. 2014). Increasing student numbers can be challenging from a placement design perspective. Health organisations require adequate space and resourcing and appropriate clinical rotations to allow students the opportunity to demonstrate required competencies. Strategies are needed during the placement design phase to avoid additional pressure on clinical educators. Development and utilisation of novel collaborative placement models and activities, such as Peer Assisted Learning (PAL) and Interprofessional Education (IPE), and the use of technology in teaching may reduce clinical educator placement strain while offering additional education and training opportunities for students (Nyoni et al. 2021).
Clinical educator experiences have been characterised as stressful, with negative impacts on service delivery and work satisfaction (Sevenhuysen and Haines 2011;Lo et al. 2017). A complex interplay of internal and external factors contributes to clinical educators perceptions of support and capability. Internal factors may include clinical education experience, job satisfaction, personality traits and feelings of burnout (Allsbrook et al. 2016); external factors may include inadequate resources, the number or duration of student placements and student underperformance (Rudland et al. 2010). Overwhelmingly, studies that have identified challenges experienced by clinical educators suggest additional training as a key support strategy to prevent or resolve these issues, yet few have proceeded with intervention trials to test this theory or look more broadly at the system. This scoping review aims to explore what is known about support for health professional educators in the workplace.

Methods
A scoping review of support for health professional clinical educators in the workplace was conducted, using the framework initially described by Arksey and O'Malley (2005) and further expanded by Levac et al. (2010) and Peters et al. (2020). This scoping review report follows the PRISMA-ScR (Tricco et al. 2018) and was certified as a quality assurance activity (Eastern Health QA 21-059 and Monash University 31188).
A scoping review was chosen to map and summarise the existing evidence with the protocol developed by the team at the outset but not prospectively registered. The search strategy was constructed using a Participant, Context, Concept (PCC) framework. Inclusion criteria: Participants -Clinical educators of pre-qualification students from any health profession Context -Clinical workplace/healthcare setting Concept -Educator support need described (either recommended or requested) Exclusion criteria: Studies reporting on educators working exclusively in academic or clinical simulation settings.

Research question
The research question for this scoping review was: What do clinical educators report they need and/or what supports are described?

Information sources and search strategy
An academic librarian assisted with the development of the search strategy. Ovid Medline, CINAHL, ProQuest and PsycINFO electronic databases were searched from 1 January 2005 up to 21 October 2020. The search was limited to peer-reviewed publications inclusive of dissertations and practice guides (e.g. AMEE guides) where full text was available in English. A search strategy for one database is presented in Table 1.

Study selection
Identified records were uploaded into Covidence and duplicates were removed. Title and abstract screening and full-text screening steps were performed in duplicate by two investigators (MF and DT) against eligibility criteria with conflicts resolved by discussion to consensus.
Decision rules that provided direction for inclusion included: met the population, context, concept criteria described support (as a noun or a verb) described or recommended support/s to remediate described barriers (investigators did not infer support based on described challenges/barriers). no limitation on who described or recommended the support e.g. clinical educators, academics, clinicians, administrators, or students

Data charting and synthesis
First level of analysis Data charting was managed in an electronic spreadsheet. Multiple iterative rounds of coding were conducted by the team of four reviewers. Records were divided into four sets prior to charting and each reviewer considered a different set of records in each round. Thus, all reviewers considered all records during four rounds of coding and review with constant revision and refinement. The conventional inductive content analysis (Hsieh and Shannon 2005) approach used was iterative, with investigators immersing themselves in record text to obtain a sense of the data in order to develop an initial coding scheme.
In the first round of coding reviewers charted data relevant to the review question. At this point, one reviewer (DT) grouped the charted codes into initial themes. At the outset of the second round, reviewers met and formulated initial definitions for themes based on relationships and links between codes (Table 2). Subsequent rounds of charting (rounds 2-4) repeated the process with each reviewer applying the charting process to the subsequent set of records. This charting process resulted in the refined codebook.

Second level of analysis
At the completion of the initial thematic analysis, a suite of cross-cutting themes that spanned across the types of support was recognised (Table 3). Category definitions were devised by identifying relationships and links between support types. The categories of support were recognised to operate at varying healthcare system levels. This second level of analysis to code the extracted data by category and implementation level was undertaken by DT and MF.

Stakeholder consultation
Three clinical educators experienced in workplace educator support not involved in the review or analysis (one from medical, nursing and allied health) provided feedback on the refined codebook to gauge the alignment of this review with the audience it sought to inform prior to finalisation.

Reflexivity
All members of the research team have either held or continue to hold, educational leadership roles within an Australian healthcare teaching hospital. The research team has all previously worked as clinician educators; three of the team have completed postgraduate health professional education qualifications. The researchers' personal perspectives were managed in two ways. Firstly, the team met on multiple occasions during the data interpretation stage to compare our interpretations and challenge each other's interpretations across different clinical environments for different health professions. Secondly, broader stakeholder feedback was sought and minor amendments were made before finalisation of the themes.

Selection of sources of evidence
The database search returned 5280 records. Three additional records were manually added. Titles and abstracts of 4770 records were screened following the removal of duplicates. Of these, 376 records were screened at the full-text stage with 50 records identified as eligible for inclusion ( Figure 1).

Characteristics of included records
The characteristics of included records are described in Table 4. Most records were research reports (n ¼ 37; 74%).

Synthesis of results
Following the initial charting round, codes were created to reflect the types of support identified. Codes were initially grouped into 15 themes. Subsequent rounds of charting refined codes and themes, resulting in 12 final support themes ( Table 2). Categories of support that cut across themes included the tangible nature of support, including infrastructure and human resources, the information required to fulfil the clinical educator role, and the communication within and across organisations. The five identified support categories were: Practical (P) -Provision of human resources, physical assets, financial remuneration or time (example codes: external evaluator, administrative support, workload flexibility) Relationship (R) -Interaction, collaboration and/or communication that supports and/or enhances clinical educator activities (example codes: peer discussion, mentorship, networks) Advocacy (A) -Attitude, action or behaviour that promotes, protects and/or values the work of clinical educators (example codes: autonomy, commitment, space for education in the delivery of patient care) Capability (C) -Support that improves skills required for clinical education activities (example codes: professional development, credentialing, lead clinical educator) Knowledge (K) -Information that builds the knowledge required for clinical education activities (example codes: directional material, instructional material, information prior to placement)  Furthermore, support implementation levels were categorised as: Individual (I)support for an individual educator Unit/team (U)support for more than one educator within a team or work unit Organisation (O)support for units or teams within an organisation System (S)support that involves more than one organisation At the conclusion of data charting and analysis the data was reviewed to confirm alignment with coding categories and implementation levels. Table 3 provides examples of fully analysed data.
A sunburst chart was created to visualise the relationship between themes, support categories and implementation levels ( Figure 2). No theme had all five categories represented within or across implementation levels. Personal resources had the largest representation of support types across categories and levels of implementation. These were weighted towards the knowledge, relationship and capability categories. Community of practice had the second largest representation of categories which tended more towards the practical and relationship support types. Most themes had at least three categories of support. Placement preparation had the lowest diversity of support categories with only two types, knowledge and capability, represented. Three themes had one category represented across all implementation levels (personal resourcescapability, community of practicerelationships, and recognition and remunerationpractical). With respect to implementation level across themes, twice as many support categories were represented at the organisation and system level compared with the unit and individual level. All categories were represented across all levels of implementation with the exception of advocacy not appearing at the unit level. Dedicated education roles and leadership support categories were limited to the organisation and system level.

Discussion
The aim of this scoping review was to explore the multiple levels of health professional clinical educator support in the workplace. Consideration of educator support through a learning organisation lens (Bohmer and Edmondson 2001), has captured the vast heterogeneity of implemented or requested support. The primary analysis identified 12 support-type themes. Some, like personal resource development, are entrenched mainstays within the system of health professional capability building, others like communities of practice, are emerging supports being trialled within the educator community (Cruess et al. 2018). Secondary synthesis established five 'categories of support', providing an alternate view of the support types that may influence clinical educator capability. These categories represent direct and indirect forms of possible support for educators and at which system-level strategies may capture relevant stakeholders. Clinical educators commonly request information to improve their knowledge for their teaching role (Bearman et al. 2018). For clinicians, evidence-based clinical practice is widely accepted; this should be expanded to evidence-based education practice (Harden et al. 1999). Clinical educators require information prior to student placement commencement, including material to guide placement design, delivery or models (Hanson and DeIuliis 2015;Alpine et al. 2019). Expanding health professions student numbers and proportional increases in clinical placement requests make the traditional apprenticeship model of 1:1 supervision unsustainable. In response, novel placement models involving student pairing or group activities within placement have been established. These approaches are supported when clinical educators receive information about student placement requirements prior to placement commencement (O'Keefe et al. 2012;Hilli and Melender 2015). Information communicated by education providers should include special needs or reasonable accommodations that students require in addition to placement requirements, to facilitate student pairing and supervisor matching, and placement design that meets students' clinical needs (L'Ecuyer 2019; Farlie et al. 2020). This may include manuals and handbooks of placement requirements, frameworks and guidelines supporting direct student supervision, strategies to manage common challenges, and procedures for failing students (Rodger et al. 2008;Flynn et al. 2016;Yepes-Rios et al. 2016;Copes et al. 2018;Farlie et al. 2020). It has been suggested that centrally locating instructional and directional materials on web-based platforms may maximize accessibility (Rodger et al. 2008).
Health service education roles could be more clearly established with lead clinical educators or education teams, as additional sources of support for clinical educators. Dedicated education roles, also referred to as clinical fieldwork coordinators, practice tutors or placement learning teams, support clinical educators and students (Hanson and DeIuliis 2015;O'Connor et al. 2019;Weber et al. 2019). The support these roles offer clinical educators goes beyond information provision, to skill development, local training, enhanced communication between health services and education providers and administrative support (Smith et al. 2009;Wray and McCall 2009;Grealish et al. 2010;Weber et al. 2019). Lead clinical educators may take responsibility for or support clinical educators with formative and summative assessments (O'Connor et al. 2019;Weber et al. 2019). Combined, these supports from lead educators or educator teams may result in greater standardisation and rigor in the assessment of health professions students by improving clinical educator competence or confidence (O'Connor et al. 2019).
In practical terms, clinical educators require sufficient physical space to educate students. Interestingly, the physical resource of space appeared across several studies but other types of infrastructure and equipment resources were seldom described (Dawes and Lambert 2010;Hanson and DeIuliis 2015;Esteves et al. 2019). This finding is surprising; it was expected that information technology infrastructure would be identified as essential support. This was also highlighted by the external stakeholders consulted who expected to see this form of support represented in the review data, particularly with recent transitions to electronic medical records and virtual patient consultations via telehealth. Clinical educator requests for protected time to support educator responsibilities were identified in this review (O'Keefe et al. 2012;Davison et al. 2019;Elmberger et al. 2019;Wallin et al. 2020). Furthermore, several types of human resource support were identified including sharing a load of educational activities or responsibilities with other staff or support to reduce the clinical patient load of an educator to dedicate more time to student supervision (Dawes and Lambert 2010;Bearman et al. 2013;Hilli and Melender 2015;Elmberger et al. 2019;Farlie et al. 2020;Wallin et al. 2020). Both support types are more easily enacted with financial remuneration directed to sufficient staffing for both clinical care and education (Rodger et al. 2008;Heale et al. 2009;Wilson et al. 2011;Reeves et al. 2012;Woodall et al. 2018;Elmberger et al. 2019). Clinical educators reported the effort of clinical placement provision for students was infrequently acknowledged. Recognising clinical educator contributions may simply be a token of appreciation in the form of a certificate, or more substantial offers of access to free or subsidised education and training opportunities, textbooks or university libraries and other resources (Rodger et al. 2008;Wilson et al. 2011;O'Keefe et al. 2012;Hilli and Melender 2015;van den Berg et al. 2017;Woodall et al. 2018).
Relationships within and across teams and organisations were an identified support need. At the individual level, this need was described as fulfilled within clinical supervision, mentoring and coaching partnerships (Wray and McCall 2009;Nasser et al. 2011;Grymonpre et al. 2016 Schoo and Kumar 2018). These relationships allow clinical educators to share knowledge, skills, resources and responsibilities across teams, professions and organisations. Through a varied skill mix and collective learning (Bohmer and Edmondson 2001), opportunities for innovation in clinical education are created which can flow-on to enhance clinical educator capability within and outside these relationships. These relationships also enable alignment of attitudes, behaviours and actions conducive to promoting, protecting and valuing the work of clinical educators. This advocacy spans physical resources, personal resources and reward or recognition (Rudland et al. 2010;Reeves et al. 2012;Elmberger et al. 2019;Esteves et al. 2019;Wallin et al. 2020). It is described in many forms, including national commitment and institutional leadership (Rodger et al. 2008;Reeves et al. 2012). A common theme identified in this scoping review was that, while essential within the healthcare sector, clinical education is not valued or prioritised. Consequently, supports required to fulfil these responsibilities are often the last to be considered and the first to disappear when there is pressure on the system (Elmberger et al. 2019).
Culture reflects attitudes, beliefs, assumptions and rituals that drive behaviour, as such, it is not surprising that the secondary synthesis demonstrated most support is implemented at the organisation or system level (Day and Leggat 2015). However, unlike individual learning, team and organisational learning does not occur naturally but requires strategic management (Bohmer and Edmondson 2001). Implementing supports and policies at higher levels increases the likelihood of standardisation across units and individuals regardless of profession. Authentic inclusion of clinical education as an essential activity within healthcare systems requires advocacy and leadership at all levels. Clinical education is affected by service delivery changes, either directly or indirectly, and this needs to be genuinely considered in the push and pull of the ever-changing landscape of healthcare (Elmberger et al. 2019). The challenge to changing this culture however cannot be underestimated.
There are some limitations to this review. The reviewers could not meaningfully differentiate between the supports that have been implemented versus the supports that clinical educators requested. Furthermore, little is known about the impact of implemented supports. Future research should explore the feasibility and merit of these suggestions, focusing on supports beyond increasing professional development opportunities. This research would benefit from a systems-based approach, engaging key stakeholders across and within organisations, with consideration of diversity across health professions and implications for applicability in different healthcare settings.

Conclusion
This review is unique in its synthesis of clinical educator support in the workplace through a learning organisation lens. It highlighted opportunities in the development and implementation of clinical educator support in research and practice. A diverse range of existing, recommended or requested supports beyond professional development could assist clinical educators in healthcare, although, few have been evaluated for their efficacy and impact.
Consideration needs to be given to the applicability, efficacy and resourcing of any newly integrated support to ensure it is sustainable, addresses the pressure points and improves clinical educator capability. To enable this, leadership and commitment are required at all levels across both the healthcare and education sectors advocating for adequate support that reflects the task being asked of clinical educators, and the responsibility of training the future healthcare workforce.