By: Lydia S.T. Lau, RN
Most readers of this blog may assume that trainees in the health professions, specifically in the clinical workplace, follow, on average, a smooth developmental pathway characterized by gradually increasing autonomy and gradually decreasing supervision, ending with a readiness for unsupervised practice. (Chen et al. 2024) But is that always true or necessarily optimal? In my school of nursing in Singapore, which applies competency-based education (CBE) and works with Entrustable Professional Activities (EPAS), we modulate supervisory effort differently.
Singapore nursing education
Let me give some background. In Singapore, clinical education for nursing is a collaborative effort between nursing educational institutions and healthcare providers, strongly supported by the Ministry of Health (MOH) and the Singapore Nursing Board (SNB). MOH plays a key role by funding nursing schools to procure clinical instructional and preceptorship services from healthcare institutions. While the allocation and deployment of suitable clinical instructors and preceptors fall under the purview of healthcare institutions, SNB provides accreditation to educational and clinical partners, ensuring the quality and standards of clinical training are upheld.
Supervisor trainee ratios
Clinical instructors (CIs) supervise junior nursing students, typically in Year 1, Year 2, or the first semester of Year 3. The CIs are required to have a recognized educational qualification and a minimum of three years of clinical experience. Each CI is assigned a group of students, up to a maximum of 12, throughout the 2 to 4-week clinical placement periods. CIs are allocated protected time to carry out their supervisory, teaching and assessment responsibilities. They also collaborate with ward staff to gather feedback on students’ performance, enhancing the learning experience through multi-source evaluation.
When the students progress into their senior years and enter the consolidation clinical practice phase, they undertake a final 10-week clinical posting. Instead of one CI to supervise up to 12 students, here, students are allocated individually across various wards or clinical settings for their consolidation placement. At this stage, each student is assigned one to two preceptors who provide close, individualized supervision. This intensive mentorship is considered crucial, as students are expected to function at a novice registered nurse’s level upon completing the posting. The preceptorship model provides a platform for close supervision. Initially, the entrustment level may be low as the students learn to manage multiple patients in the complex clinical setting. However, as they progress and gain more experience, their entrustment level is expected to increase to level 4, i.e. limited supervision. Across the 10 weeks, the actual supervision decreases. This ensures a safe and supported environment for consolidating clinical competencies and professional identity.
Why is more supervision necessary for seniors?
Transition-to-practice students often experience heightened psychological and emotional stress stemming from multiple converging pressures, including elevated expectations from both themselves and their clinical supervisors, the looming prospect of graduation, the urgency of securing employment, and the high-stakes nature of final assessments. This confluence of academic, professional, and personal demands can compromise their learning efficacy and clinical performance if not adequately supported. Consequently, providing supportive supervision is critical during this transitional phase, offering not only guidance in clinical decision-making but also emotional reassurance and structured feedback. Such support fosters resilience, promotes professional confidence, and safeguards both student development and patient safety. (King et al., 2020)
In the transition from student to certified nurse, senior nursing students often encounter significant challenges stemming from unfamiliarity with the full scope of professional roles and responsibilities. This transition marks their initial exposure to independently managing multifaceted clinical duties, including simultaneous patient care tasks and interprofessional collaboration within high-acuity environments. As a result, these students frequently demonstrate reduced confidence and clinical assurance, underscoring the critical need for structured and direct supervision. Such guided support not only facilitates safe and competent practice but also fosters the development of clinical judgment and professional identity during this pivotal phase of professional socialization. (Mussi et al., 2019)
As senior nursing students assume increased clinical responsibilities, they are frequently entrusted with managing multiple patients, executing complex procedures, delegating tasks, and initiating clinical reasoning and judgment. These expanded expectations, while essential for the transition to professional practice, inherently elevate the risk of adverse outcomes should errors occur. The complexity and acuity of such responsibilities amplify the potential for clinical and ethical consequences if mishandled, particularly in the absence of sufficient support or oversight. Consequently, this stage of practice demands rigorous supervision, reflective learning opportunities, and scaffolded autonomy to ensure both patient safety and the consolidation of professional competence.
Readiness and capability for higher responsibility
Readiness and capability to assume higher clinical responsibility among nursing students are highly individualised, reflecting diverse learning trajectories and varying degrees of prior experience, confidence, and cognitive integration. The progression toward independent practice is not uniform; somewhat, it is shaped by each student’s unique learning curve, which influences the time required to attain readiness for more complex clinical tasks. This variability necessitates adaptive supervision strategies and individualized learning plans that accommodate differing paces of development. Recognizing and responding to these differences is essential to ensure that entrustment decisions are based on demonstrated competence rather than chronological milestones or academic standing alone.
Entrustment in clinical education is fundamentally task-specific rather than time-dependent, recognising that competence in nursing practice cannot be assumed solely based on the student’s academic progression or duration of training. A senior nursing student may be deemed capable of performing basic nursing care independently; however, more complex clinical responsibilities, such as case management, care coordination within interprofessional teams, and conducting shift handovers, necessitate close supervision and guided practice. These advanced tasks require nuanced clinical judgment, communication proficiency, and systems thinking, which must be individually assessed to ensure safe and effective care. Therefore, entrustment decisions should be grounded in demonstrated competence for each specific task, rather than generalized assumptions based on seniority. (Lau et al., 2020)
Implications for supervisors and educators
The transition of nursing students into professional roles necessitates deliberate and responsive supervision from clinical educators, underscoring the importance of moving beyond assumptions rooted in academic seniority or prior academic performance. Supervisors must adopt a nuanced approach that evaluates learners based on observable behaviors, demonstrated competence, and contextual demands. The use of an EPA-based framework enables precise calibration of supervision levels to support safe, progressive autonomy. Emphasizing assessment for learning and as learning, not merely of learning, fosters preparedness for high-stakes evaluations while reinforcing clinical reasoning and reflective practice. Ongoing, specific feedback is essential to guide targeted development and uphold patient safety. Crucially, supervisors must recognize that the journey toward independent practice is inherently non-linear; temporary regressions in supervision levels should be viewed not as failure but as natural components of the learning process. Thus, effective individualized supervision must be adaptive and responsive, reflecting the evolving readiness of the learner rather than adhering to static or automatic protocols.
About the Author:
Siew Tiang (Lydia) Lau, RN, Associate Professor and Director of Education, Deputy Head of the Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore.
Acknowledgement
I extend my sincere gratitude to Professor Olle (Th.J.) ten Cate for his critical review and insightful feedback for this article.
References
- Chen HC, Ladenheim RI, Schumacher DJ, Chou FC, ten Cate O. Graded autonomy and grounded self-determination in health professions education. In: ten Cate O, Burch VC, Chen HC, Chou FC, Hennus MP. (Eds). Entrustable Professional Activities and Entrustment Decision-Making in Health Professions Education, Chapter 3, pp. 25–33. [2024] London: Ubiquity Press. DOI: https://doi.org/10.5334/bdc.c
- Lau, S. T., et al. (2020). Development of undergraduate nursing entrustable professional activities to enhance clinical care and practice. Nurse Education Today, 87, 104347Mussi, F. C., Pires, C. G. D. S., Carneiro, L. S., Costa, A. L. S., Ribeiro, F. M. S. E. S., & Santos, A. F. D. (2019). Comparison of stress in freshman and senior nursing students. Revista da Escola de Enfermagem da USP, 53, e03431.
- King, C., Edlington, T., & Williams, B. (2020). The “ideal” clinical supervision environment in nursing and allied health. Journal of Multidisciplinary Healthcare, 187-196.
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