A realist evaluation of clinical supervision of Advanced Clinical Practice learners in general practice teams.

Health service policies describe the complex intervention of supporting primary care services through introducing advanced clinical practice (ACP) roles. There is concern this policy may lead to further inequities in access to primary care. Understanding what mechanisms enable these roles to support the delivery of generalist care remains a key research gap.

A critical factor in ACPs adapting to their new roles is clinical supervision from experienced general practitioners (GPs). A realist evaluation of clinical supervision of these ACPs identifies key mechanisms that enable novice generalists to learn, adapt and integrate into general practice teams.

An initial programme theory is developed through a combination of retroduction, stakeholder consultation and literature review that contains fifty-four candidate mechanisms. Paired, realist semi-structured interviews are undertaken with 13 ACPs new to primary care and 12 of their supervising GPs. Half of participants are working in practices serving communities in the most deprived quintile. Transcribed interviews are analysed using qualitative methods adapted for realist studies to test the plausibility of candidate mechanisms and identify new ones.

A refined programme theory is produced with mechanisms clustered around six themes: establishing safety, developing mutual trust, sharing clinical reasoning, promoting reflection, allowing self-direction, and collaborating in care. Situational aspects relating to practitioner, the practice team and the population served are also identified. The refined programme theory develops current understanding of clinical supervision in primary care environments.

The programme theory is supported by middle-range theories from education and training, suggesting it is transferable to other learning environments. Understanding key supervision mechanisms that support practitioner development and integration into primary care settings has relevance for clinical learners from professional groups and at all stages of training, as well as wider strategy to support primary care within healthcare systems. Future dissemination and research to explore this area further is suggested.