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Med Educ Online
Med Educ Online
Medical Education Online
1087-2981
Taylor & Francis

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10.1080/10872981.2024.2405473
2405473
Version of Record
Research Article
Research Article
Constructing psychometric measurement of a past supervised experience scale with educational roles to investigate the relationship between being instructed, being supported, and being supervised for attending physicians in teaching hospitals – a questionnaire survey
Y.-C. LIN AND L.-C. OU
MEDICAL EDUCATION ONLINE
https://orcid.org/0000-0002-4162-7614
Lin Yu-Chih a b c
https://orcid.org/0009-0002-9001-0343
Ou Ling-Chun b d
a Department of General Internal Medicine, Kaohsiung Medical University Hospital , Kaohsiung, Taiwan
b Department of Clinical Education and Training, Kaohsiung Medical University Hospital , Kaohsiung, Taiwan
c Department of Medical Humanities and Education, School of Post Baccalaureate Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
d Department of Family Medicine, Kaohsiung Medical University Hospital , Kaohsiung, Taiwan
CONTACT Ling-Chun Ou suloveorange@gmail.com Teaching and Learning Development and Resource Center, Kaohsiung Medical University, No.100, Ziyou 1st Road, Sanmin Dist, Kaohsiung City 807377, Taiwan
18 9 2024
2024
18 9 2024
29 1 2405473Integra18 9 2024
Integra18 9 2024
02 7 2024
12 8 2024
12 9 2024
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
2024
The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

ABSTRACT

Purpose

Although school-based planned education has steadily been introduced, master-apprentice learning is still an indispensable part of medical education. All medical clinical teachers begin their careers as medical students, often without knowing exactly how they will learn to teach. Kilminster and Jolly identified three primary functions of clinical supervisors including clinical teaching, support and guidance, and work supervision. Therefore, we designed a study using questionnaires to assess the three factors of clinical educators for past supervised experiences, including ‘being instructed,’ ‘being supported,’ and ‘being supervised,’ based on Kilminster and Jolly’s illustration in 2000, to see the relationship between the three factors mentioned above.

Materials and Methods

The study started with a literature review to construct the essential items regarding past supervised experiences of physicians as clinical teachers. We invited 10 experts from fields including medical education and experienced clinical teachers to assess the content validity. One hundred physicians in teaching hospitals were sampled for the preliminary test. Another 364 physicians in teaching hospitals were sampled for the formal study of confirmatory factor analysis and pathway analysis.

Results

The” Past Supervised Experiences with Educational Roles Scale” showed satisfying reliability with all Cronbach’s α values exceeding .80, and three factors from supervised experiences were identified, including ‘being supported,’ ‘being instructed,’ and ‘being supervised.’ In our model, the ‘being supported’ experience could positively affect ‘being supervised’ with significance, directly and indirectly, by being instructed.

Conclusions

Our study developed a validated instrument that allows investigation of the formation of better-supervised experiences from current physicians. Our findings inspired us to focus more on supportive coaching in teaching and supervising medical trainees. Our study indicated that faculty development for skills of supporting students is crucial to effective clinical teaching and supervision.

KEYWORDS

Past supervised experiences
clinical supervision by attending physicians
confirmatory factor analysis
item analysis
educational role
National Science and Technology Council 106-2511-S-037-004 This research was supported by a research grant from the National Science and Technology Council in Taiwan under the project number NSTC 106-2511-S-037-004.
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pmcIntroduction

The profession of medicine, one of the oldest vocations, thrives on the continual evolution of professional knowledge and skills, the societal value of professional services, and the capability for ongoing development within the professional community [1]. Historically, medical education relied on and evolved around the master-apprentice model. Despite the progressive development of modern medical schools and teaching hospitals that has led to more structured educational systems and more programmatic learning, the master-apprentice model remains an integral component of medical training [2,3].

All medical clinical teachers begin their careers as medical students, often without knowing exactly how they will learn to teach. The journey from medical student to attending physician in a teaching hospital involves a protracted professional growth process. Numerous experiences and events during this period significantly influence the teaching capabilities and methodologies of the attending physicians [4]. Additionally, while transitioning to attending physicians, they assimilate pedagogical knowledge through their experiences and observing their mentors [5].

In earlier phases of medical education, teaching proficiency was often equated with medical expertise; it was presumed that a doctor with superior professional skills would naturally be an effective educator. Nonetheless, as medical education evolves from the traditional apprenticeship system to a curriculum-based approach, it becomes apparent that medical expertise and clinical teaching skills are distinct competencies [5,6]. This is not a new theory when an American educator Kilpatrick [7] introduced the concept of simultaneous learning to analyze physicians’ professional development education and suggested that acquiring teaching skills could be considered an incidental form of learning within the broader context of professional training in 1951.

In medical professional education, medical students and early-stage clinical physicians acquire most of their professional knowledge through coursework or clinical practice. However, for areas not explicitly covered in the curriculum, such as clinical teaching methods and styles, learners often gain preliminary insights into pedagogy by observing their supervisor’s teaching methods and experiencing firsthand the impact and effectiveness of these approaches [8,9]. Steinert [4] underscored the significance of experiential learning within the framework of teacher competency development, categorizing it into three modes: learning by observation, learning by doing, and reflection on experience in 2010. Of these, learning through observation, or imitative learning, is prevalent among physicians acquiring professional attitudes and skills [10–13]. In social cognitive theory, Bandura [14] posited that observational learning is a crucial social learning mechanism in 1986, where individuals enhance their learning outcomes and acquire new behaviors by observing others within a learning context.

From the role theory perspective, the transition from trainee to clinical instructor represents a shift in identity and role expectations, potentially leading to differing perceptions and experiences [15]. Whether the insights and emotions experienced as a trainee resonate when one assumes the role of clinical instructor and how these influence subsequent teaching behaviors warrant further empirical investigation.

Taiwan has developed a modern medical education system with similar educational structures and accreditation systems to ensure the quality of medical education. Even so, the master-apprentice model remains the center of clinical education, and there are yet more dynamics between clinical teaching abilities that should be disclosed and applied to the design of the faculty development program. However, there is a notable deficiency in teaching-related training during the professional development of doctors, as well as a lack of research and practical engagement in clinical teacher training. Kilminster and Jolly [16] identified three primary functions of clinical supervisors in 2000: clinical teaching, support and guidance, and work supervision. Some literature proves that a supportive atmosphere will promote better clinical work performance [17–20], individual supportive education will lead to better learning outcomes [21–23], and learner-centered education will promote better clinical work performance [24,25]. However, the interrelationships between clinical supervisors’ different roles and abilities in such role-set remain unclear. These would be important research questions to answer and provide better information for faculty development. Therefore, we have designed a study to develop a series of questionnaires based on the three main functions proposed by Kilminster and Jolly [16] in 2000 to explore the interrelationships among these factors that could help faculty development.

Materials and methods

According to Kilminster and Jolly’s model about the three primary functions of clinical supervisors in 2000 and the literature mentioned above [16–25], we hypothesized as follows: 1. ‘Being supported’ experience could positively affect ‘being supervised’. 2. ‘Being supported’ experience could positively affect ‘being instructed’. 3. ‘being instructed’ experience could positively affect ‘being supervised’. Then this study developed a psychometric instrument in traditional Chinese using the following process to approach our research questions, which require access to the past learning experiences of physicians currently teaching.

Development and validation of our study

Questionnaires in traditional Chinese assessing past supervised experiences, including clinical teaching, support coaching, and work supervision, were developed with approval from the Institutional Review Board in Kaohsiung Medical University Hospital (IRB protocol number KMUHIRB-E(I)-20170052). The content validity was evaluated by a panel of 10 experts from fields including medical education, educational research, hospital administration, and experienced clinical teachers at a medical university hospital in January 2018 in Southern Taiwan. Preliminary tests for readability and feasibility were conducted with 100 physicians working in teaching hospitals in Southern Taiwan, followed by a formal study for detailed analysis.

Precursor study in January 2018

Questionnaire development

The ‘Past Being-Supervised Experiences by Educational Roles Scale’ was designed to capture three primary functions: ‘being instructed’, ‘being supported’, and ‘being supervised’, as identified in 2000 by Kilminster & Jolly [16]. This scale included five items per category, with responses scored on a 5-point Likert scale from 1 for strongly disagree to 5 for strongly agree [26,27].

Content validity, feasibility, and readability testing

Feedback from the expert panel led to the revision of three negatively phrased items to positive statements, enhancing clarity and aligning with observational learning principles in social learning theory. These revisions aimed to gauge the extent to which past clinical supervisors made a lasting impression through their educational roles (Table 1) [14,28,29].Table 1. The content of the ‘past supervised experiences with educational roles scale’.

Item number	Content	
1	Past teachers will provide rich clinical teaching guidance	
2	Past teachers would take the time to teach me clinically.	
3	Past teachers would value my learning of clinical knowledge and skills	
4	I was deeply impressed by the good clinical teaching methods of past teachers	
5	I will imitate the good teaching practices of past teachers	
6	Past teachers create a friendly and interactive atmosphere	
7	Past teachers would have cared about my life balance while working	
8	My past teachers helped me when I had difficulties in work and study	
9	I was deeply impressed by the supportive tutoring I received from past teachers	
10	I will follow the good practices of past teachers who supported and coached me	
11	Past teachers had a serious and strict attitude towards the quality of clinical work.	
12	Teachers used to give me clear instructions for clinical work.	
13	The supervision of my past teachers enabled me to improve the quality and effectiveness of my work.	
14	I was deeply impressed by the effective way past teachers supervised clinical work	
15	I will follow the effective supervision methods of past teachers to lead my students	
The original language of the questionnaire is traditional Chinese for the readability of participants.

Preliminary data analysis

A purposive sampling method was employed, engaging 100 attending physicians who signed the informed consent from seven teaching hospitals in Southern Taiwan for preliminary testing, resulting in a 100% response rate with no invalid or incomplete responses [30]. SPSS for Windows version 26.0 and AMOS for Windows version 21.0 were utilized for item analysis, factor analysis, and reliability testing to ensure the appropriateness of the pre-test questions, from which a formal questionnaire about three dimensions including past experiences of ‘being instructed’, ‘being supported’, and ‘being supervised’ were identified after factor analysis was developed. Item Analysis: Conducted using the extreme group inspection and homogeneity test methods. Items were retained if the Critical Ratio value exceeded 3.00, indicating discriminative solid power [31].

Homogeneity Test: This involved assessing the correlation between each item and the total scale score, with a correlation threshold of .40, indicating adequate homogeneity [31–33].

Kaiser-Meyer-Olkin (KMO) and Bartlett’s Test of Sphericity: Following satisfactory KMO, Bartlett’s test, and Measures of Sampling Adequacy (MSA) values, confirmatory factor analysis was performed to ensure the factorial structure of the questionnaire was suitable for the data set [31–34].

Formal study from February 2018 to April 2018

Participants and sampling methods

Given the specialized nature of the participant group and the complexity of their professional work, purposive sampling was employed. From a total potential participant pool of 1,653 attending physicians in Southern Taiwan, 400 attending physicians were suggested to be selected for the study, distinct from those involved in the preliminary test. A total of 364 participants working as attending physicians from 7 teaching hospitals in Southern Taiwan completed the questionnaires after informed consent [30,35]. SPSS for Windows version 26.0 and AMOS for Windows version 21.0 were utilized for Confirmatory Factor Analysis and Pathway Analysis.

Confirmatory factor analysis

This analysis was based on literature recommendations, with criteria including a KMO value above .80, significant Bartlett’s test results (p < .05), and MSA values above .50 [31–33].

Reliability analysis

The scale’s reliability was confirmed by measuring Cronbach’s alpha coefficient, which assessed the internal consistency of the ‘Past Supervised Experiences with Educational Roles Scale’ [36].

Results

The results from the preliminary test to verify this instrument and the statistical analysis of the formal questionnaire survey are detailed below.

Preliminary test results

As detailed in Table 2, all items from the ‘Past supervised experiences with educational roles scale’ were retained after item analysis, adhering to established criteria from relevant statistical literature. In Table 3, The scale demonstrated satisfactory reliability, with all Cronbach’s α values exceeding .80, indicating high internal consistency [31].Table 2. Summary of item analysis for preliminary questionnaires (n = 100).

item	Extreme group comparison	Correlation between items and total score	Homogeneity test	Reserved
(Yes/No)	
Critical ratio	between items and total score	between correction items and total score	α value after deleting item	communality	Factor loading	
1	8.456***	.678***	.630	.942	.458	.676	Yes	
2	6.182***	.691***	.644	.941	.484	.696	Yes	
3	10.924***	.795***	.751	.939	.629	.793	Yes	
4	9.054***	.765***	.723	.940	.592	.770	Yes	
5	7.242***	.735***	.683	.941	.521	.722	Yes	
6	8.500***	.722***	.678	.941	.518	.720	Yes	
7	9.442***	.806***	.776	.939	.664	.815	Yes	
8	8.299***	.764***	.721	.940	.581	.762	Yes	
9	8.713***	.811***	.775	.938	.662	.814	Yes	
10	7.222***	.728***	.680	.941	.513	.716	Yes	
11	10.269***	.763***	.727	.940	.587	.766	Yes	
12	9.868***	.780***	.746	.939	.625	.791	Yes	
13	8.962***	.766***	.725	.940	.589	.767	Yes	
14	8.360***	.712***	.665	.941	.516	.718	Yes	
15	7.706***	.737***	.689	.940	.530	.728	Yes	
criteria	≥3.000	≥.400	≥.400	≤.946	≥.200	≥.450	 	
***p < .001.

Table 3. Summary of the reliability analysis for the preliminary questionnaires (n = 100).

Aspects	Item numbers	items	Cronbach’s α	Overall Cronbach’s α	
Being Instructed	1, 2, 3, 4, 5	5	.838	.946	
Being Supported	6, 7, 8, 9, 10	5	.878	
Being Supervised	11, 12, 13, 14, 15	5	.866	

Results of the formal study

Confirmatory Factor Analysis of the ‘Past supervised experiences with educational roles scale’

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for the scale was .923, and Bartlett’s test of sphericity yielded a χ^2 value of 1412.587, which was significant (p < .001). This indicates the data’s appropriateness for factor analysis. Factors were named consistent with the role classifications of clinical supervisors in the literature. Further analyses included normality tests, offending estimate tests, model fit assessments, convergent validity, and discriminant validity (Tables 4–7). Additionally, pathway analysis and impact effects for the overall model were examined (Table 8) [31–34].Table 4. Summary of the confirmatory factor analysis (n = 364).

items	Mean	SD	Skewness	kurtosis	SFL (t)	S.E.	SMC	EV	α	CR	AVE	
A	4.03	 	 	 	 	 	 	.252***	.838	.727	.536	
1	3.94	.715	−.505	.694	.703 (14.286)***	.157	.396	.258***	 	 	 	
2	4.13	.730	−.678	.773	.798 (17.082)***	.152	.581	.193***	 	 	 	
3	3.83	.865	−.615	.485	.757 (15.813)***	.185	.573	.319***	 	 	 	
4	4.14	.741	−.757	1.147	.762 (15.969)***	.158	.637	.229***	 	 	 	
5	4.13	.780	−.650	.229	.629 (12.410)***	.177	.495	.367***	 	 	 	
Mardia coefficient	19.204	Totle items* (total items + 2) = 35, Mardia = 19.204 < 35	
B	3.958	 	 	 	 	 	 	.314***	.878	.756	.621	
6	3.88	.727	−.248	−.173	.772 (16.709)***	.150	.595	.213***	 	 	 	
7	4.00	.739	−.536	.533	.830 (18.299)***	.148	.673	.178***	 	 	 	
8	3.81	.840	−.416	−.174	.822 (18.373)***	.168	.676	.228***	 	 	 	
9	4.05	.772	−.659	.722	.757 (16.263)***	.161	.574	.253***	 	 	 	
10	4.05	.775	−.483	−.196	.766 (16.551)***	.160	.587	.247***	 	 	 	
Mardia coefficient	24.007	Totle items* (total items + 2) = 35, Mardia = 24.007 < 35	
C	4.014	 	 	 	 	 	 	.260	.866	.728	.599	
11	3.94	.736	−.321	−.139	.694 (14.361)***	.159	.588	.280***	 	 	 	
12	4.06	.723	−.536	.559	.827 (18.426)***	.145	.635	.164***	 	 	 	
13	3.93	.838	−.650	.469	.777 (16.772)***	.173	.603	.278***	 	 	 	
14	4.05	.772	−.623	.618	.797 (17.423)***	.158	.684	.217***	 	 	 	
15	4.09	.744	−.506	−.024	.767 (16.470)***	.155	.482	.228***	 	 	 	
Mardia coefficient	25.406	Totle items* (total items + 2) = 35, Mardia = 25.406 < 35	
A: Being Instructed; B: Being Supported; C: Being Supervised; SD: Standard deviation; SFL: Standard factor loading; S.E.: Standard error; SMC: Squared multiple correlation; EV: Error variance; CR: Composite reliability; AVE: Average variance extraction; ***: p < .001.

Table 5. The summary of discriminant validity about the ‘past supervised experiences with educational roles scale’ by bootstrap confidence interval method. (n = 364).

 	 	95% Confidence Interval	
Aspects	Estimate	Lower	Upper	p value	
Being Instructed ↔ Being Supervised	.879	.820	.930	.002	
Being Supported ↔ Being Supervised	.899	.851	.943	.002	
Being Instructed ↔ Being Supported	.898	.848	.941	.002	

Table 6. Summary of the model-of-fit for the overall model (n = 364).

Statistical test quantity	Reference value	Measured value	Corrected value by Bootstrap method	Judgment after correction (Yes/No)	
Absolute fit index	X2	p > .05	783.084*	144.865*	No	
X2 /df	1 ~ 5	9.001	1.665	Yes	
GFI	>.9	.736	1.013	Yes	
AGFI	>.9	.636	1.017	Yes	
RMR	<.08	.038	.038	Yes	
SRMR	<.08	.066	.066	Yes	
RMSEA	<.08	.148	.043	Yes	
Incremental fit index	NFI	>.9	.809	.965	Yes	
NNFI	>.9	.790	.983	Yes	
CFI	>.9	.826	.986	Yes	
RFI	>.9	.770	.957	Yes	
IFI	>.9	.827	.986	Yes	
Streamlined fitness indicators	PNFI	>.5	.671	.799	Yes	
PGFI	>.5	.533	.734	Yes	
Critical Number	>200	51	−1068	No	
*: p < .05.

Table 7. Summary of the parameter estimation for the overall model (n = 364).

Parameter	Standard regression coefficient	Standard error	t value	Error variance	Squared multiple correlation	
Being instructed → 1	.697	.103***	9.497	.263	.485	
Being instructed → 2	.777	.112***	9.971	.211	.604	
Being instructed → 3	.747	.129**	9.812	.329	.559	
Being instructed → 4	.768	.112***	9.932	.225	.589	
Being instructed → 5	.669	.107***	9.590	.335	.448	
Being supported→ 6	.751	.149***	16.341	.230	.564	
Being supported→ 7	.802	.147***	18.018	.194	.644	
Being supported→ 8	.807	.167***	18.165	.246	.651	
Being supported→ 9	.786	.155***	17.492	.227	.619	
Being supported→ 10	.790	.155***	17.619	.225	.625	
Being supervised→ 11	.704	.091***	10.302	.273	.495	
Being supervised→ 12	.816	.097***	11.015	.174	.666	
Being supervised→ 13	.778	.109***	10.862	.276	.606	
Being supervised→ 14	.794	.102***	10.927	.220	.630	
Being supervised→ 15	.774	.096***	10.913	.221	.599	
Being supported→ being instructed	.898	.229***	8.914	.048	.806	
Being supported→ being supervised	.569	.309***	4.539	.055	.835	
Being instructed→ being supervised	.368	.131***	3.037	.298	
***: p < .001; **: p < .01.

Table 8. Pathway analysis checklist and impact effect analysis (n = 364).

latent dependent variable	potential independent variables	Path value	Direct effect	Indirect effect	Overall effect	
Being Instructed	Being Supported	.898***	.898***	No	.898***	
Being Supervised	Being Supported	.569***	.569***	.330***	.899***	
Being Supervised	Being Instructed	.368***	.368***	No	.368***	
***: p < .001.

Normality test

The results indicated satisfactory normality with absolute skewness values and kurtosis, which were all less than 2 in each question. Mardia’s coefficients below the threshold were calculated as the product of multiplying the number of questions by the number of questions plus 2 (Table 4) [37,38].

Offending estimate test

Standard factor loadings of each question were all below .950, error variances were favorable, and all t-values were statistically significant (p < .05), confirming that the model did not violate any estimation assumptions (Tables 4 and 7) [39].

Model fit analysis

From Table 6, The model’s initial absolute fit was unsatisfactory because of the larger value of the original ratio of chi-square to the degree of freedom. Therefore, we needed to differentiate the possible cause, whether it was the larger sample size or the inadequate model. After applying Bollen-Stine bootstrap correction methods, the ratio of chi-square to degrees of freedom improved to 1.665, meeting the acceptable threshold. The reason why our initial indices of model fit was a larger sample size. All other indices except for the chi-square and the critical number also met the established criteria, rendering the model fit acceptable [40].

Convergent validity

Composite reliability values all exceeded .70, and average variance extracted (AVE) values were above .50, indicating strong convergent validity (Table 4) [39,41].

Discriminant validity

After using the Bootstrap Confidence Interval method, the value of 95% confidence interval for the aspects between ‘instructed’ and ‘being supervised’, ‘being supported’ and ‘being supervised’ as well as ‘being instructed’ and ‘being supported’ were .820 ~ .930, .851 ~ .943 and .848 ~ .941, respectively. All confidence intervals mentioned above did not include 1, confirming adequate discriminant validity (Table 5) [42].

Pathway analysis and impact effect

The analyses revealed that ‘being supported’ had both a direct positive effect on ‘being instructed’ with the value of .898 (p < .001) in the pathway coefficient and an indirect positive impact on ‘being supervised’ with the total effect coefficient of .899 (p < .001) through ‘being instructed’ with the indirect effect value of .330 (p < .001), demonstrating significant interdependencies among these factors (Table 8 and Figure 1) [43]. Figure 1. The diagram of the overall model for the ‘past supervised experiences with educational roles scale’.

Discussion

Attending physicians in teaching hospitals are often clinical teachers or supervisors with different roles and functions in clinical education. While adult learning could be related to prior life experience, the past supervised experiences of physicians as clinical supervisors would be valuable information to hospital faculty development. We hypothesized that past supervised experiences could be measured with a psychometric test based on an educational role-set framework, and there would be interrelationships between different role-related supervised experiences. Our study followed a rigorous process to develop a psychometric instrument and questionnaire survey, ensuring the quality of this research and providing clear answers to our research questions.

Clinical teaching, support and guidance, and work supervision are critical and interrelated elements of good clinical supervision. These three elements are also the essential functions of physicians as clinical supervisors. Whether these three functions work independently, simultaneously, or inter-relatively remains unknown. Our study developed a series of questionnaires based on the three main role functions proposed by Kilminster and Jolly [16] to investigate the supervised experiences of current attending physicians in teaching hospitals to explore the interrelationships among these factors. Our findings indicated that the ‘being supported’ experience could positively affect ‘being supervised’ with significance, directly and indirectly, by ‘being instructed’. In addition, our study proved our hypothesis and demonstrated that the ‘being supported’ experience also indirectly influenced ‘being supervised’ by ‘being instructed’.

Our study also provided evidence to reveal how these three role functions of the clinical supervisor would dynamically interrelate with each other. From Figure 1, our results showed that ‘being supported’ experiences positively influenced ‘being supervised’ experiences directly. The result was compatible with past studies that support the idea that trainees will get better work performance in a supportive atmosphere created by the clinical supervisors [17–20]. Besides, ‘being supported’ experiences in our study also positively influenced ‘being instructed’ experiences directly, and the result was compatible with past literature illustrating individual supportive education will encourage learning outcomes in medical education [19,21–23]. Another result in our study also showed that ‘being instructed’ experiences positively influenced ‘being supervised’ experiences directly, and the result was similar to the past literature stating that well-designed and learner-oriented education will lead to good performance in the workplace [24,25]. In addition, our findings revealed that ‘being supported’ experiences positively influence ‘being supervised’ indirectly through ‘being instructed’ (Figure 1). Altogether, our result was compatible with the literature illustrating that individualized education programs with a supportive atmosphere will result in better performance in the workplace [44–46].

The literature emphasizes the crucial role of tension management in teaching and supervising trainee’s professional activities [17,47]. Adequate support and coaching reduce the risk of workplace burnout and underscore the significance of mentorship in fostering professionalism among medical trainees [48–50]. However, the literature above illustrates the effectiveness from a student’s perspective instead of a medical educator’s perspective derived from past supervised experience. Our study of past supervised experience from clinical educators based on medical educators’ perspectives could prove that an impressive, comfortable, supervised experience will impact the future when a student becomes a clinical teacher.

These findings and insights suggest that mentorship could be a fundamental reason the master-apprentice model remains vital in medical education [2,3]. Despite the acknowledged importance of these interactions, quantitative studies exploring the specific relationships between coaching, teaching, and supervision are scarce. A deeper understanding of these relationships could inform the design of training curricula for medical supervisors. For example, the medical institution could conduct mentor training courses including how to communicate with medical students, how to understand the stressors of medical students, and how to deal with the students’ pressure before the clinical educators instruct or supervise medical students.

Although our model’s initial fit indices were suboptimal, the acceptable model fit was noted after applying the Bootstrap correction method, indicating that the large sample size might have contributed to the poor initial fit. Consequently, the ‘Past supervised experiences with educational roles scale’ demonstrated acceptable validity and reliability after adjustment [51]. Though questionnaires about past supervised experience were collected based on clinical supervisors’ recall, and we did not measure the behavior change as an outcome to see the impact on teaching behavior, we still proved that the ‘being supported’ experience could positively affect ‘being supervised’ with significance, directly and indirectly, by ‘being instructed’. As a result, the impact of past supervised experiences on teaching behavior may be a future issue for further research.

Thus the implications of our study suggested that curricula for physicians to be more competent clinical supervisors in teaching hospitals should include components on ‘how to provide supportive coaching’ before ‘how to teach students’ and ‘how to supervise students’. By fostering a supportive and engaging learning environment, medical educators can enhance students’ educational experience. Then, teaching and supervising will be practiced effectively in sequence.

Conclusions

The ‘Past supervised experiences with educational roles scale’ developed in our study indicated that ‘being supported’ positively impacts ‘being supervised,’ whether directly or mediated through ‘being instructed’. This finding advocated an increased focus on supporting coaching in teaching and supervising medical trainees. Such approaches could potentially enhance the effectiveness of medical training and support the development of future healthcare professionals. That is, the curriculum about ‘how to support students’, ‘how to teach students’ and ‘how to supervise students’ may be designed sequentially for medical educators in teaching hospitals in the future. Moreover, the recent students may become better clinical supervisors in the future.

Acknowledgments

The authors would like to thank Dr. Chih-Hung Chen from Kaohsiung Chang Gung Memorial Hospital, Dr. Ji-Wei Lin from E-DA Hospital, and Dr. Ching-Huang Lin from Kaohsiung Veterans General Hospital for their assistance.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Author contributions

We confirmed the corresponding author and the 1st author had read the journal policies and submitted this manuscript following those policies.

Ethics statement

The study was approved by the Institutional Review Board in Kaohsiung Medical University Hospital (IRB protocol number KMUHIRB-E(I)-20170052).
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