Nurse Education Today 34 (2014) 783–788

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Review

Supervisors' experiences of workplace supervision of nursing and

paramedic students in rural settings: A scoping review
Franziska Trede a,⁎, Celina McEwen a,1, Amanda Kenny b,2, Peter O'Meara b,3
a
The Education For Practice Institute, Charles Sturt University, Locked Bag 450, Silverwater, NSW 2128, Australia
b
La Trobe Rural Health School, Faculty of Health Sciences, La Trobe University Health Sciences, Bendigo, VIC 3550, Australia

a r t i c l e i n f o s u m m a r y

Article history: Objectives: We present our findings from a scoping review that sought to identify what is known about nursing
Accepted 7 October 2013 and paramedic clinical supervisors' experiences of their supervision practices in rural settings. Our interest in
these two groups is based on the central role that nurses and paramedics play in rural health care.
Design: Scoping reviews support identification of a broad range of literature, including all types of study designs.
Keywords: We adopted Arksey and O'Malley's five-stage approach: identifying the research question; identifying relevant
Supervision
studies; study selection; charting the data; and collating, summarising and reporting results.
Supervisor
Rural
Data Sources: Databases searched included Academic Search Complete, Springer, Factiva, ProQuest, Ebsco,
Nursing Informit, VOCEDplus and Scopus.
Paramedicine Review Method: Based on our research question and inclusion and exclusion criteria we selected relevant
literature and summarised and reported it using Arksey and O'Malley's framework.
Results: The review yielded five articles from four countries: Sweden, Belgium, Malaysia and Australia.
Conclusion: From this scoping review, we identified key themes related to supervisors' experiences, including
clarification of expectations, support from managers and colleagues, the need for shared understanding between
university, students and supervisors and required skills and competence in supervising students.
© 2013 Elsevier Ltd. All rights reserved.

Introduction under-resourcing, geographical isolation and poor access to the internet

In this article, we present our findings from a scoping review of the
literature on supervisors' perspectives of their experiences in super-
vising nursing and paramedic students undertaking rural placements.
Understanding supervisors' perspectives can help identify issues
associated with student supervision and develop understanding of the
enablers that support quality supervision practices. Many different
definitions, roles and understandings are used for the term supervisor
such as mentor, preceptor and educator (Billay and Yonge, 2004;
McCarthy and Murphy, 2010). For the purpose of our review, we
defined supervisors as health care professionals employed within a
health care agency who mentor, monitor, teach, provide feedback and
assess undergraduate students.
In our review, the key focus was on supervisors of nursing and
paramedic students. Our focus on rural, which we define as non-
metropolitan, was triggered by findings from a study by Siggins Miller
Consultants (2012) that identified that workforce maldistribution,
⁎ Corresponding author. Tel./fax: +61 2 9752 9003.
E-mail addresses: ftrede@csu.edu.au (F. Trede), cmcewen@csu.edu.au (C. McEwen),
a.kenny@latrobe.edu.au (A. Kenny), p.omeara@latrobe.edu.au (P. O'Meara).
1
Tel.: +61 2 9752 9013; fax: +61 2 9746 3647.
2
Tel.: +61 3 5444 7545.
3
Tel.: +61 3 5444 7870.
(characteristics of clinical rural settings) have a major impact on quality
student supervision. The focus on nursing and paramedicine was fuelled
by the central role that these two groups play in ensuring sustainable
health service delivery in rural areas (Duckett and Kenny, 2000; Kenny
and Duckett, 2003; Mulholland, 2010). In a study by Mulholland
(2010), a dearth of literature relating to rural paramedic education was
identified. In the rural nursing literature, Kenny and Duckett (2003)
state that the key to building a sustainable rural nursing workforce is
ensuring that undergraduate nursing students in rural settings have a
positive and well-supported experience. In the recently released
Australian National Strategic Framework for Rural and Remote Health
(Australian Health Ministers Advisory Council Rural Health Standing
Committee, 2012), quality student education in health settings is
identified as central to sustainable rural health delivery.
Nursing students in Australia spend approximately 1000 h in
unpaid, supernumerary placements over the course of a three or four
year degree (Kenny et al., 2012). For paramedicine, there are no
prescribed hours for student placement, but placement is integral to
course accreditation. Given the central role of student placement for
both nursing and paramedicine, we were surprised by our cursory
review of the Australian literature that yielded few studies on the
experiences of student supervisors in the rural context.
Mills et al.'s (2010, p.10) integrative review on the status of rural
nursing identified the importance of rural nurses as ‘translators of

0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
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784 F. Trede et al. / Nurse Education Today 34 (2014) 783–788
local culture’ and identified their role as crucial in supporting neophyte
clinicians. More recently, researchers have identified the need to foster
and develop clinical academic leadership in the rural context (Doherty
et al., 2013; Bish et al., 2012), but an apparent lack of knowledge on
the experiences of supervisors in the rural context makes clinical
academic leadership development difficult. We were keen to complete
a broader, international review to identify what is known about nursing
and paramedic clinical supervisors' experiences in rural settings.
Background
Globally, student placement experiences in health settings are
important for many reasons (Kilminster and Jolly, 2000). It socializes
students into their future professional role and identity (Higgs, 2012).
While student experience in health care settings is a feature of most
health professional courses, universities and health care agencies, two
of the main actors in preparing the future health workforce, have
different views and interests in relation to supervision practices
(Billett, 2001). Universities have a major interest in ensuring that their
students have effective and productive placement experiences, because
in most cases, placements are a requirement for course accreditation. In
contrast, the prime objective of health care agencies is to ensure a
sustainable workforce for the delivery of quality, safe and timely
healthcare that meets efficiency and productivity indicators. This
productivity imperative, based on ever tighter budgets and under-
resourced health care services, attenuates health care agencies' interest
to offer placements, because in many instances, it requires staff take on
the role of supervisor, in addition to their main clinical role. This often
results in students being seen as a burden or a risk to productivity,
which in turn places low priority and value on student supervision
(Heath, 2002; Barton et al., 2005; Sanderson and Lea, 2012). From a
student and staff perspective there are consequences, with poor
experiences leading to student disenrollment or dissatisfaction (Leduq
et al., 2012; Boyle et al., 2008; Lucas and McCall, 2013) and for
supervisors', burn out, withdrawal from taking students on placement
or even resignations (Sanderson and Lea, 2012).
This situation creates a challenge for universities, especially within
nursing and paramedicine, as their student intake increases and the
competition amongst universities for placements escalates accordingly
(Siggins Miller Consultants, 2012; Barnett et al., 2010; Magnusson
et al., 2007). This competition amplifies the need to make effective use
of placements and to understand what is required from students,
supervisors and the workplace environment.
Many student placement models have been developed worldwide. In
some cases, researchers have reported on reducing the responsibility and
time involved in supervising students by employing supervisors through
universities (Sanderson and Lea, 2012; Lavender, 2013). University staff,
government agencies, and health services have focused on developing
learning and teaching resources for supervisors and providing training
and support (Health Workforce Australia, 2011). Innovative approaches
have addressed peer learning models (Hoffman et al., 2008), student-
led clinics, where senior students mentor junior students (Grealich
et al., 2013), and interprofessional placements where supervision is
shared across professions (Jansen, 2008). Few studies have addressed
the wider health care agencies' workplace learning environment
(Grealich et al., 2013; Siggins Miller Consultants, 2012; Moscaritolo,
2009; Robinson et al., 2007).
A comprehensive literature review and stakeholder consultation
report completed by Siggins Miller Consultants (2012) documented
key enablers and barriers to quality student placements. Authors of
this report identified enablers that improve student placement expe-
rience including: a culture of quality; effective supervision; learning
opportunities; effective communication and collaboration; and re-
sources and facilities to conduct placements. In the report it is stated
that two factors clearly hinder satisfaction and success in the health
care learning environment: occupational stress; and workplace
incivility and aggression. The consultants identified that most enablers
and barriers relate to socio-cultural aspects of the workplace, rather
than to micro skills in supervising students.
While the authors of the Siggins Miller report (2012) highlight
enablers and barriers to quality student placements, the focus is on
student needs rather than on supervisors' experiences and needs. Within
the nursing and paramedicine literature a similar trend is evident. That
is, there is a growing knowledge base on the experiences of students
during health care placements (Williams et al., 2012; Lucas et al., 2013;
Henderson, 2012; Wallin et al., 2013) but little is known about the
experiences of supervisors and what they perceive as enablers and
obstacles to their supervision practices.
Methods
A scoping review was undertaken to identify what is known about
the experiences of rural nursing and paramedicine supervisors of
undergraduate students. Scoping reviews are useful to map, collate and
summarise existing literature on a topic. Unlike systematic reviews, the
focus of a scoping review is not on the assessment of the quality of the
research (O'Malley and Croucher, 2005), rather, the approach supports
identification of a broader range of literature, including all types of
study designs (Arksey and O'Malley, 2005). The work of Arksey and
O'Malley provides a useful methodological framework for scoping
reviews. For this study, we adopted their five-stage approach: identifying
the research question; identifying relevant studies; study selection;
charting the data; and collating, summarising and reporting results.
Identifying the Research Question
Arksey and O'Malley (2005, p.23) recommend that a broad question
and key terms are central to ‘generate breadth of coverage’. As our aim
was to capture a broad range of literature pertaining to the experiences
of supervisors of nursing and paramedicine students, the research
question ‘what is known about nursing and paramedicine clinical
supervisors' experiences of their supervision practices in rural settings?’
guided the search strategy.
Identifying Relevant Studies
Researchers have identified the need to establish clear criteria to
place some boundary around a study and achieve a balance between a
thorough review and the practicalities of time and cost limitations
(Kenny et al., 2013). In this study, key search terms were identified
and the following Boolean search string was developed: supervisor*
AND student* AND (nurs* OR paramedic*) AND work environment
AND (region* OR rural OR remote). The use of truncated words and
wild cards (in this instance *) allowed a broadening of the search to
include all terms with the same root word. In order to refine this search,
additional inclusion and exclusion criteria, consistent with our review
purpose, were also developed. These are outlined in Table 1.
An initial search of Google Scholar was carried out to determine the
likely size and relevance of key terms, but the results were not included
in our findings due to the lack of replicability of this search strategy
(Giustini and Kamel Boulos, 2013). A search of the Cochrane Library
failed to retrieve any registered Cochrane reviews. Databases searched
included Academic Search Complete, Springer, Factiva, ProQuest,
Ebsco, Informit, VOCEDplus and Scopus.
Study Selection
Using the developed search terms, 92 articles were identified. The
title, abstract and keywords of the articles were scrutinised against the
inclusion and exclusion criteria, with the research team involved in
agreeing and confirming the elimination of irrelevant studies. Many
articles that initially appeared relevant were excluded. For example,
 F. Trede et al. / Nurse Education Today 34 (2014) 783–788
Sanderson and Lea (2012) explored experiences of clinical supervisors
but had to be excluded because their clinical supervisors were
employed within the university system. McCarthy and Murphy (2010)
explored clinical supervisors' experiences, but had no focus on rural
settings. Through the process of elimination, nine articles were
identified that appeared to meet the inclusion criteria. Full text versions
of these articles were read by a minimum of two team members. The
ensuing discussions enabled us to further cull articles that did not
match the inclusion and exclusion criteria. One such article was a
position paper that critically discussed how to prepare supervisors for
their role, without exploring their supervision experiences (Edwards,
2011). Through the process of refinement, five articles were identified
as being directly relevant to the research question and matching the
inclusion and exclusion criteria.
Data Charting and Collation
Consistent with the fourth stage of Arksey and O'Malley's framework,
we developed summaries of each article and documented data related to
author, journal, publication year, setting, country, research question or
aim, and theoretical framework/research design (see Table 2).
Summarising and Reporting Findings
The final stage of Arksey and O'Malley's framework is the provision
of an overview of the selected articles. As the purpose of this scoping
review was to identify peer-reviewed articles that presented studies
that specifically illuminated rural paramedicine and nursing student
supervisors' experiences of their supervision practices, our reporting
on the identified articles focuses on enablers and barriers for effective
supervision as well as on key messages from each article and their
recommendations for further research.
Results and Discussion
This scoping review study yielded five articles, all pertaining to
nursing in countries as varied as Sweden, Belgium, Malaysia and
Australia (two articles). There was a noticeable absence of articles
relating to the experiences of supervisors of paramedicine students. Of
the five articles in the nursing literature, two were written by the
same authors, reducing research of clinical supervisors' experiences of
workplace supervision to four research teams only. In what follows,
we present the results and discussion under the headings enablers
and barriers for effective supervision, key messages from each article
and recommendations for further research.
Enablers for Effective Supervision
Within the five nursing articles, a recurring enabler of effective
clinical supervision was perceived to be the quality of the relationship
between the organisation and the university. Good preparation of
courses and ongoing professional development were identified as
Table 1
Inclusion and exclusion criteria.
Criterion Inclusion
Time period January 2000 to December 2012
Language English
Type of article Original research article published in a peer
reviewed journal
Study focus Nursing or paramedicine
Setting Rural, regional or remote
Geographical place of study International
Population and sample Supervisors of nursing or paramedicine students
employed within the health care system
785
important. Attention to relationships, courses and professional devel-
opment was viewed as integral to ensuring that supervisors have the
confidence and appropriate knowledge to teach and assess students
(Huybrecht et al., 2011). Organisational factors, including acknowl-
edgement of the responsibility associated with the supervisor role,
information packages for students and supervisors (Bos et al., 2009),
and receiving support from colleagues (Huybrecht et al., 2011) were
seen as important for effective supervision. Continuous professional
development opportunities provided by universities, together with
constructive feedback, were described as central processes in becoming
effective supervisors (Huybrecht et al., 2011). Authors of two articles
(Chuan and Barnett, 2012; Reid-Searl and Happell, 2011) discussed
the importance of reciprocity between students and supervisors as a
key enabler. Furthermore, in these articles, positive attitudes and
mutual respect of students and supervisors were seen as beneficial.
Reid-Searl and Happell (2012) added supervisors' willingness to share
their knowledge and preparedness to answer students' questions as
key enablers for effective supervision.
Barriers for Effective Supervision
Lack of time and heavy workloads were reported as key barriers in the
five articles reviewed (Huybrecht et al., 2011; Bos et al., 2009; Reid-Searl
and Happell, 2011, 2012; Chuan and Barnett, 2012). Poor communication
and support were seen as obstacles to quality supervisory practices. More
specifically, Bos et al. (2009) listed lack of support from clinical managers
and peers; and Reid-Searl and Happell (2011) discussed poor commu-
nication between university and supervisors as a barrier for effective
supervision. An additional barrier, only mentioned by Reid-Searl and
Happell (2011), was poor attitudes of supervisors towards students. At
a skill level, Huybrecht et al. (2011) found poor teaching and assessing
skills as barriers to positive supervision experiences. Lastly, Reid-Searl
and Happell (2012) identified poor preparation and not valuing the
supervision role as dominant barriers in their study.
Key Messages From the Identified Articles
Each of the five reviewed papers had different key messages or
arguments. These were closely related to their unique research foci,
within the theme of supervisors' experiences of workplace supervision.
One argument, which was shared in two studies (Bos et al., 2009; Reid-
Searl and Happell, 2011), was the need to foster close relationships and
strong cooperation between university and supervisors. Bos et al.
(2009) found that a benefit of strong cooperation between university
and supervisors was helping supervisors keep up-to-date with changes
in nurse education. They highlighted the need for good support from
clinical managers. In addition to communication with universities,
Reid-Searl and Happell (2011) identified three other key themes that
influenced supervisors' experiences: student attitudes that influence
the quality of supervision provided; students feeling pressured to
conform to, rather than to question clinical practices; and being sole
assessor of students (closely linked to the previous theme). Huybrecht
Exclusion
Any study outside these dates
Non-English
Any publication that was not original research, peer-reviewed, journal
article and/or unpublished. For example, PhD theses, reports were excluded
No reference to nursing or paramedicine
No reference to rural, regional or remote
Nil
Studies that did not report the experiences of nursing or paramedicine
student supervisors; studies that reported the experiences of clinical
supervisors employed within the university system
 786
Table 2
Summary of identified and reviewed articles.

Authors/title Journal/year Setting/supervision model Country Research question/aim Theoretical framework/research design

Bos, E., Anna Löfmark, Lena Törnkvist
District nurses' experience of supervising
nursing students in primary health care:
A pre- and post-implementation
questionnaire study
Nurse Education Nursing Sweden Investigate district nurses' experience of supervising nursing Descriptive, quantitative design
in Practice, 2009 Primary health care in regional and students in primary health care before and after the Evaluation study
urban centres. implementation of a new supervision model Questionnaire covered the following areas:
1. Background, capabilities, skills: 12 items
2. Performance of supervision: 25 items

F. Trede et al. / Nurse Education Today 34 (2014) 783–788

Huybrecht, S., Wim Loeckx, Yvo Quaeyhaegens,
Danielle De Tobel, Wilhelm Mistiaen
Mentoring in nursing education:
Perceived characteristics of mentors and
the consequences of mentorship
Chuan, O. L., T. Barnett
Student, tutor and staff nurse
perceptions of the clinical learning
environment
Reid-Searl, K., Brenda Happell
Factors influencing the supervision of
nursing students administering medication:
The registered nurse perspective
Reid-Searl, K., Happell, B.
Supervising nursing students
administering medication:
a perspective from registered nurses
Nurse Education Nursing
Today, 2011 Seven regional and university
hospitals in Antwerp
Nurse Education Nursing
in Practice, 2012 Private hospital.
Staff nurses maintained a patient
case load when they supervised
student clinical instructors did not.
Collegian, 2011 Nursing
Public health care facility in regional QLD
Journal of Clinical Nursing
Nursing, 2012 Health service in regional Queensl
and from a spread of specialty areas
including medical, surgical, accident
and emergency mental health,
paediatrics and maternity.
Focus was on supervision of nursing
students administering medication
opinions
3. Organisation of supervision: 14 items
Belgium How mentors perceive themselves? Questionnaire and semi-structured interviews.
Which problems do they encounter?
What do mentors consider the advantages/drawbacks?
What is the main source of help in mentoring students?
Malaysia Describe and compare the perceptions of student nurses, Descriptive design using a structured, self-administered
staff nurses and nurse tutors towards the clinical learning questionnaire with 0students, clinical supervisors and
environment (CLE) and to identify the key characteristics nurse staff (three groups)
of CLE that enhanced or inhibited students' learning in a
Malaysian hospital
Australia The aim of this study was to explore the opinions and Qualitative exploratory research
insights of registered nurses regarding the supervision Two focus groups
of nursing students administering medication.
Australia Explore the attitudes, opinions and experiences of Qualitative exploratory design
registered nurses with regard to the supervision of Focus groups
undergraduate nursing students during the
administration of medications in the healthcare setting.
By enhancing our understanding of the education and
skill development of nursing students in this respect,
the ability to produce registered nurses with safer
practices in administering medication can be influenced
 F. Trede et al. / Nurse Education Today 34 (2014) 783–788
et al. (2011) found that it was important to clearly understand what was
meant by being a supervisor. Chuan and Barnett (2012) highlighted that
students and supervisors had different perceptions of the clinical
learning environment. Students focused on learning needs, whereas
supervisors focused on service needs. Their key argument was that
these competing interests (service versus learning) could be overcome
by identifying shared understanding between students and supervisors.
Reid-Searl and Happell (2012) identified three key themes: standard of
supervision; beneficial experience; and preparation for supervision.
They not only argued that supervisors need to ensure they meet
university requirements, but also asserted that supervisors need to
regularly prepare for their supervision.
Further Research
Two research teams (Chuan and Barnett, 2012; Reid-Searl and
Happell, 2011, 2012) offered very distinct recommendations for further
research. Chuan and Barnett (2012) recommended further research
using their questionnaire instrument, designed around their six
characteristics needed for a quality clinical learning environment:
workplace atmosphere, supervision by staff nurses and the clinical
instructor, student satisfaction, the theory–practice gap, and peer
support. Reid-Searl and Happell (2011) recommended exploring clinical
practice models that best suit students' learning needs. They especially
mentioned exploring shared assessment practices between staff
employed within the university system and health care agencies. Reid-
Searl and Happell (2012) recommended exploration of the relationship
between supervision and error prevention in administering medication.
Because these recommendations for further research were based on
their respective study foci, of comparing nursing students, staff and
tutors' perceptions of the clinical learning environment (Chuan and
Barnett, 2012), and the administration of medication by student nurses
(Reid-Searl and Happell, 2011, 2012), it is not surprising that they provide
no recommendation about developing a better understanding of
supervisors' experiences. It should be noted that even though these
articles reported on studies conducted within rural contexts, there was
no explicit mention of the ‘rural’ experience and their recommendations
for future research did not include the experiences of supervising in rural
settings.
Conclusion
From this scoping review of nursing and paramedicine supervisors'
perspectives of their experiences in supervising students in rural
workplaces we conclude that supervisors' experiences of workplace
supervision in rural settings are an under-researched, or perhaps an
emerging area of research. Our review highlighted a lack of connection
between the rural context and supervisors' experiences and a lack of
discussion about rural specific enablers and barriers. Focusing on
training and support to enhance the capacity of individual supervisors
is an important, yet potentially narrow and unsustainable approach. It
does not take into account the impact of workplace learning culture
and the importance of this culture in enhancing rural supervision
practices and experiences. We argue that there is a need to conduct
further research in supervision, from a rural perspective, focusing on
shared responsibility, organisational support, and the tension between
practice and supervision. Further research is needed to explore
supervisors' capacity for agency and their awareness of the socio-
material forces in rural settings that shape their supervision experiences.
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