The response rate of 70% was in keeping with other surveys of ES [5
]. Approximately 60% of both trainees and supervisors reported ES at least 3 times monthly, somewhat less than previous studies, and about 75% of ES sessions lasted around 60 minutes. This suggests that up to 40% of trainees only had ES twice per month at most, and around 25% received less than 1 full hour of ES – this clearly falls short of the RCPsych requirements.
Comments from trainees and supervisors revealed that annual/study leave, clinical commitments, lack of planning and perceptions that 1 hour of ES weekly is "irksome and never necessary" or possibly "an ideal – probably a luxury not attainable in the current NHS" may be contributing to shorter, less frequent ES sessions. Overall shorter working hours for trainees, with changing shift patterns which include nightshifts and compensatory rest, combined with shorter 4 month posts and a mixture of psychiatric and non-psychiatric trainees are all challenges in achieving "gold standard" ES, especially if neither trainees nor supervisors see it as a priority.
In addition to these opinions and practical challenges, supervisors' uncertainty over structure continues to be an issue. One supervisor commented that "We really don't have clear guidelines on what we are expected to do". While it is important that ES is flexible and tailored to serve individual trainees' unique professional and personal needs, there are certain components that are relevant for all trainees, and clear guidelines on structure and content have been suggested, assessed and published [7
There were some discrepancies between what was reported by supervisors and trainees. One possible explanation for these may simply be recall bias, in that supervisors/trainees retrospectively remembered and reported the presence or absence of certain things that either pleased, disappointed or interested them. It may also be the case that trainees did not identify certain aspects of ES when their supervisors did not make them explicit, e.g. setting ground rules and giving feedback. This would fit with anecdotal evidence from the local medical school at the University of Glasgow, where it has been reported that medical students frequently fail to identify when their supervisors give them feedback unless it is either written down or presented explicitly to them as "feedback". In part because of small numbers, this study was not designed to identify any significant relationships between individuals' previous and current experience of ES and their opinions on ideal frequency or duration.
As the quality of supervision has been reported as being the single most important factor in determining trainee satisfaction, it is essential that trainees and supervisors alike make the most of this aspect of postgraduate psychiatric education and training [15
]. All supervisors should ensure that they are aware of the published guidance and use it to adapt ES to each of their trainees' individual needs. Supervisors may also benefit from the recently developed RCPsych College Accredited Training Module in ES, where observed role-play is used to train supervisors in a variety of potential ES scenarios [16
]. In addition, college tutors (identified psychiatrists with responsibility for overseeing postgraduate training and education in individual training schemes) have key roles to play in drawing supervisors' attention to the published guidance and training opportunities, and monitoring the quality of ES provided through feedback from trainees.
Although trainees and supervisors agree that responsibility for ES is shared equally between them, it may well be the case that each should take relatively more responsibility for different aspects. For example, perhaps supervisors should take the lead in structuring ES by ensuring that 1 hour of ES is prioritised and timetabled weekly, and by advising on content at the start of the trainees' posts. Conversely, trainees should take more responsibility for the content of ES as their attachments progress, particularly as the time belongs to them and should be tailored to their individual educational needs. The old adage of "the more you put in to it, the more you'll get out of it" is undoubtedly true for both supervisors and trainees, and it is significant to note that Lawley et al
. (1995) found that the quality of supervision was subjectively improved by mutually agreeing agendas and preparing in advance [17
]. Following the RCPsych guidance about using appropriate documentation such as that required for WPBAs is likely to facilitate the shared responsibility for ES [18
WPBAs may well facilitate and enhance various aspects of ES, including its occurrence, frequency and duration. As a required component of approved postgraduate training curricula and assessment, WPBAs certainly provide motivation for trainees to meet regularly with their supervisors for the purpose of focusing on knowledge, skills and attitudes which are relevant for senior psychiatric practice [19
]. Likewise, WPBAs may help to provide a degree of clarity for some of the structure and content of ES. If done well, and trainees ensure that they are assessed by different senior psychiatrists and others within the multidisciplinary team, there is the potential for WPBAs to improve and broaden psychiatrists' skills in a more reliable and consistent manner than previously achieved [11
]. Hopefully this will benefit patients and colleagues alike.
The RCPsych is keen to encourage the development of mentoring relationships for all psychiatrists and mentoring is a specified element of the educational supervisor's role [2
]. However, as one supervisor in this study commented, there can be "tension between mentoring and [the] objective appraisal of [a trainee's] performance". A conflict of interests between mentoring and assessment has been discussed in both the healthcare and educational literature [20
]. Identified tensions include the "moral dilemma" of judging performance while being a mentor, and the finding that mentors' assessments are more favourable than those of non-mentors [21
]. Concerningly, mentors have been reported as "failing to fail" their mentees even when they have doubts about their performance [23
]. This in itself merits ensuring that trainees' WPBAs are not done solely by their supervisors. One further issue for psychiatry trainees is that using precious ES time for WPBAs introduces the potential for the increased emphasis on their appraisal to displace other educational needs. This is especially significant when ES as currently provided is falling short of existing RCPsych standards. It is therefore important that the use of ES time for WPBAs is monitored to ensure that ES remains tailored to individual trainees' needs. It is reassuring that this study in one typical UK basic psychiatry training scheme did not identify any negative effects of WPBAs on ES, but this should be subject to ongoing review across psychiatric training in the UK to ensure that trainees continue to receive high quality personalised ES which fulfils RCPsych requirements.