Micromanagement in clinical supervision: a scoping review

Micromanagement in clinical supervision in health professions education generally refers to supervision characterized by unproductive excessive control and attention to detail. It can affect autonomy, competence, well-being of learners, teamwork, and ultimately patient care. Despite its potential negative impact on learners and patients, no comprehensive review of this phenomenon has been conducted. This scoping review aims to explore the breadth of extant literature concerning micromanagement in clinical supervision in health professions education and map the body of research on the topic. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis﻿: Extension for Scoping Review (PRISMA-ScR). We searched eight databases, and the final review and analysis comprised 12 articles that examined micromanagement in clinical supervision across health professions education. Micromanagement was conceptualized as ineffective supervisory practices such as undue scrutiny, excessive control, domination, and ineffectual leadership. Conversely, alternatives to micromanagement included entrusting or granting autonomy, coaching for independent practice, and providing effective supervision and leadership. Overall, micromanagement was attributed to individual behavioral and personality factors, such as distrust, perfectionism, self-conviction, and low self-esteem. The consequences of micromanagement included inadequacies in professional development and well-being of trainees and patient care, and organizational dysfunction. Suggested solutions included entrusting or empowering trainees with encouragement and clear communication, open communication efforts by trainees, organizational management for quality supervision, and faculty’s valuing both clinical and educational goals. Current literature on micromanagement—in the context of clinical supervision in health professions education—was found to be sparse, implying a need for more rigorous research and discourse on this understudied area. The findings can be used to recognize, solve, and prevent the prevalent, and often unrecognized, phenomena of micromanagement, which may improve clinical supervision, the professional development of trainees and faculty, organizational management, and ultimately patient care. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-023-04543-3.


Introduction
High-quality clinical supervision is vital to the development of competent medical practitioners, and excellent patient care.Though non-existent or limited supervisory input may affect trainee learning and patient safety [1], the negative impacts of excessive supervision, or micromanagement, may also reduce the benefits of clinical supervision [2,3].Most academic healthcare organizations require clinical supervision, reflecting the belief that careful guidance can help trainees develop into independent professional decision makers and competent clinicians.At the same time, there is little empirical validation or theoretical foundation underlying such supervisory practices [4].
A few studies have shed light on some of the components of high-quality clinical supervision in health professions education (HPE).Busari and colleagues [5] reported on trainees' views of "good" and "poor" supervision.Overall, trainees felt that effective (good) supervisors provided clear explanations of their clinical opinions, gave them autonomy to enhance their experience and competence, and allowed them to engage in self-directed learning.Conversely, less skillful (poor) supervisors showed deficiencies in coaching, including ineffective communication and micromanagement that undermined trainees' autonomy and compromised their learning and, accordingly, patient safety (e.g., van de Ridder et al. [6]).Interestingly, studies suggest that too much supervision or micromanagement is more common than not enough supervision in medical education practices [1,5].
Micromanagement can be referred to as an inappropriate method employing excessive clinical supervision.Micromanagement engenders the management of personnel using excessive control or attention to detail.Exerting an excessive level of control denotes that it goes beyond a generally accepted level of input and often culminates in negative consequences.Studies report that micromanagement can have negative influences on medical training and patient care as it creates an unsafe learning environment, harms the learners in their learning, and depletes confidence in future independent clinical practice [2,3].In general, micromanagers may appear to be well intended, and in fact, are seldom aware that their behavior has negative effects on a trainee's motivation, autonomy, competence, well-being, team-work, and patient care.Among the three functions of clinical supervision that Proctor's model represents -managerial, educational and supportive- [7], the focus of micromanagement is perceived to be excessively monitoring performance, rather than providing education and support.However, recent studies have reported that micromanagement, resulting in improper intensive supervision, did not improve patient safety and outcome [8,9].Though all levels of learners (students, interns, residents, and fellows) see micromanagement as problematic [6], the phenomenon has received little attention in HPE.The concept and practice have gone largely unattended, and related issues, such as validly defining micromanagement within clinical care, understanding why it happens and what it brings about, examining consequences, and proposing solutions for the problem, have not been fully explored.Even in the business literature, only a few strategies are proposed for overcoming micromanagement [3,[10][11][12].
Establishing a theoretical basis for effective clinical supervision in medical settings would go a long way toward preventing the micromanagement of trainees.This scoping review aims to explore the breadth of the available micromanagement literature with reference to clinical supervision across HPE.This work aims to contribute to refining practices related to educating independent competent physicians and enhancing quality patient care.

Method
We conducted this study using the scoping review method to provide an overview of research available on micromanagement in clinical supervision.We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review (PRISMA-ScR) [13].We chose to conduct a scoping review rather than a systematic review because of the differences in their goals and methods.While a systematic review focuses clearly defines research questions by synthesizing evidences from best available empirical studies, a scoping review broadly addresses defined research questions by exploring breadth instead of depth of the available studies and identifying gaps within the research topic [14].Thus, a scoping review was more appropriate for our purposes since it would provide a map or a snapshot of the body of research on micromanagement in HPE.Further, our preliminary exploration showed that terms, concepts, and research designs used in relevant articles were diverse and inconsistent, making it difficult to aggregate or weigh evidence.Thus, we saw this scoping review as potentially informing future systematic reviews by providing an overview of the scope of current research and descriptive summaries, and identifying research gaps.

Search strategy
With the help of two qualified librarians, we searched eight databases judged to be the most relevant to our topic (Web of Science, Scopus, ScienceDirect, Pubmed, PsycINFO, Embase, CINAHL and ERIC).In addition, we conducted a hand search at Google Scholar in order to cover the breadth of the healthcare professions education literature.We performed all database searches on February 22, 2021 using search terms in the title, abstract, or keyword of articles according to the PCC (Population, Concept, Context) framework [13]: (a) health professions (Population); (b) micromanagement (Concept) and (c) education (Context).Full search algorithms for each database can be found in Additional file 1.Because no date range was set, all related published literature was included in the search.

Selection of sources of evidence
All authors independently assessed the title and abstract screenings and reviewed the full-texts of all papers against the eligibility criteria.Discrepancies were resolved through consensus-driven meetings focused on determining the suitability of the articles for final review.The inclusion and exclusion criteria are presented in Table 1.

Data extraction and synthesis
We extracted two types of data: study features and findings.We extracted the study features of independent articles by year of publication, country where the study was conducted, health professions discipline (medical, dental, or nursing), journal/section, workplace relationships, research method, and sample size.
We extracted the findings of the articles following a four-step procedure [15].First, we produced short summaries of each study.Second, we identified key items in the summaries, and developed a standard category template consisting of conceptualization, potential counterbalancing concepts, reasons, consequences, and possible solutions for micromanagement based on our scoping review aims.Third, we analyzed and sorted the items in each category of our template, resulting in groups of main and sub-themes.For consequences and solutions, we adopted the theoretical framework for clinical supervision developed by Rothwell et al. [16]: professional development, organizational development, and patient services.Finally, we collated the charted information, and synthesized the template into a graphical chart in order to unearth the true characteristics of all reviewed articles.We jointly and iteratively refined the interim and final outputs of the data extraction until we arrived at consensus.

Results
We identified a total of 272 articles from the 8 academic databases and an additional hand search, and then eliminated 109 duplicate articles.We screened 163 potentially relevant articles by title review, resulting in 74 articles being eliminated based on their titles, with 89 potentially relevant articles remaining for abstract review.After we reviewed these 89 abstracts thoroughly, we excluded 42 articles.We retrieved the remaining 47 articles for full-text review, after which we excluded 35 more with consensus.Details of the exclusion process along with reasons for exclusion are presented in Fig. 1.

Features of reviewed articles
The final analysis consisted of 12 articles with seven distinguishing features: (1) publication year, (2) country of the first author's institution, (3) health profession discipline (4) journal name and section, (5) workplace relationship, (6) research method, and (7) sample size, as shown in Table 2.

Synthesis of findings of reviewed articles
We identified five categories from the articles we reviewed: (1) conceptualization of micromanagement, (2) counter-balancing concepts of micromanagement, (3) reasons/influencing factors, (4) consequences, and (5) possible solutions.We sorted each consequence and solution in terms of professional development, organizational development, and patient services, according to the framework for clinical supervision developed by Rothwell and colleagues [16].Table 3 delineates five categories, main themes and their sub-themes, and provides representative phrases and their sources.Figure 2 illustrates the interconnections between main themes.

Consequences of micromanagement
We delineated and classified the variety of consequences of micromanagement into four groups, including the consequences for: (1) professional development of trainee; (2) patient service; (3) organizational development; and (4) faculty (supervisor).
The consequences for trainees' professional development were: (1) negative influence on learning environment (trainee loss of educational development and self-confidence, loss of enthusiasm and creativity) [6,21,24] and (2) a negative influence on trainee wellbeing (trainee fatigue or burnout and increased resentment, threats to psychological and physical health) [6,21,24].
Consequences for patient service referred to threats to the safety and quality of patient care [22,23].Micromanagement may result in less effective training for learners, thus influencing the effectiveness of patient care and undermining practice capacity.From the organizational development perspective, consequences for organizations were (1) organizational dysfunction [6,22,23,26] due to high staff turnover, decreased job satisfaction, absenteeism or stifled enthusiasm, and (2) a culture of abuse [6,22,23] that demoralizes trainees, harms relationships within a team, and debilitates team unity.Finally, as a consequence for faculty, damaged personal reputation was highlighted [2].

Suggested solutions
Overall, the studies reported solutions for micromanagement in terms of faculty perspective, trainee perspective, and organizational development perspective.The solutions tended to correspond to the reasons/influencing    Other steps similarly relied on introspection and selfassessment, such as of the ability to work through others effectively and their own triggers for micromanagement.
Other recommendations involved supervisors understanding the differences between support and micromanagement and knowing when to rectify incongruence, and planning for gradual improvement.Entrustment and empowerment [19,[21][22][23]25] referred to actions that would promote trainees' independent thinking and acting, perhaps by trying to take a back-stage approach to clinical oversight.Clear communication about trainees' roles and responsibility, and faculty's expectations [2,19], were also perceived as essential, as well as training in leadership and supervisory strategies Training [21,24].From the perspective of trainees' professional development, both clinical training to improve competence and efficiency, and trainee training to seek effective supervision together with a recognition of their liabilities as clinical caregivers were recommended [21], along with open communication with faculty [2,17,20] in order to identify concerns and meet their own expectations of and that of their supervisor.Suggestions linked to changes in the environment focused on enhancing organizational management -open the conversation by focusing trainee's optimal contribution; asking for feedback and areas for improvement to identify supervisor's concern; gently describing the impact of micromanagement; team members being open in their support of team goals and priorities

Organizational Development Perspective ENVIRONMENT SIDE ORGANIZATIONAL INTERVENTION
Organizational Management [2,19,24] -reducing work load pressure on 'attendings'; -being sensitive to team dynamics and hierarchy; -providing support systems and ongoing assistance for supervisors and trainees; -redefining and evaluation of quality supervision Balanced Valuing of Clinical and Educational Goals [19] -modernizing the organizations to achieve two equally important goals of improving the quality of care and enhancing residents' education Training [6,18] -organizational training on mentoring, coaching, autonomy and trust building through such actions as reducing the performance pressure or the provision of support systems that would enable quality supervision [2,19,24].Balancing clinical and educational goals also was mentioned [19], as well as organizational training, mentoring, coaching, and autonomy building [6,18].In short, the most frequently addressed concept in relevant studies of micromanagement was scrutinizing (n = 6, 50.0%) [2,6,18,[22][23][24].In contrast, autonomy or entrustment (n = 9, 75.0%) [2, 6, 18-22, 24, 26] were the most frequently mentioned contrasting concepts.The most mentioned reasons for the perpetuation of micromanagement were faculty's behavioral and personality dimensions (n = 7, 58.3%), among which distrust was the number one reason (n = 6, 50%) [2,6,17,18,23,26].In terms of consequences, the most common concern was organizational dysfunction (n = 4, 33.3%), with the foremost solution focusing on changes in supervisory leadership and management strategies geared toward entrusting and empowering trainees (n = 5, 41.7%).

Discussion
This scoping review explored the literature pertaining to micromanagement in clinical supervision in health professions education.The key messages are: (1) Micromanagement in clinical supervision was conceptualized as scrutinizing, excessive control, domination and ineffectual leadership; (2) it is attributed to faculty members' behavioral and personality factors foremost; (3) the consequence of such micromanagement likely impacts trainees' professional development and well-being, patient care, and organizational dysfunction; (4) micromanagement can be mitigated by solutions such as faculty's entrusting or empowering trainees with clear encouraging communication, open communication efforts from trainees, organization management for quality supervision, and valuing both clinical and educational goals; and (5) more research, based on a higher quality of evidence, is needed to understand and discuss micromanagement in clinical supervision.These five key messages will be discussed in turn.
Our scoping review suggests that in the field of HPE, micromanagement in clinical supervision has negative connotations, as evidenced by associated features like scrutinizing, excessive control, domination, and ineffectual leadership.Conversely, alternatives to micromanagement were essentially positive, including entrustment or granting autonomy, coaching for trainees' independent practice, and effective supervision and leadership.Nonetheless, supervisory practices associated with micromanagement mostly engender negative perceptions and, as such, the field of medicine seems more tolerant of this approach to clinical training than fields outside medicine, such as organizational management, public administration, and political science [27].In the field of organizational management, Peter Drucker's 1946 work on democracy in management (decentralizing and delegating more authority to employees) and Douglas McGregor's 1960 Theory X manager (a manager who is poor at proper delegating), criticize micromanagement as a strong disrupter of organizational life and an organizational pathology [28].However, in the health professions, the perception of micromanagement is still controversial due to the criticality of patient safety although it was reported that micromanagement does not improve patient safety and outcomes [8,9].
Given the greater tolerance for supervisory micromanagement in medical fields [27], it is reasonable to ask, what exactly is the problem with scrutinizing, i.e., monitoring every last detail or a detail-oriented faculty?Some aspects of performance by health professionals are crucially important-such as those linked to patient safety, performance and professional expertise-and may be seen as justifying 'over-management' .In fact, among physicians there has been an implicit understanding that detail-oriented, enhanced supervision is both good and necessary [29,30].Practices that promote trainees' autonomy and empowerment stand in contrast to these perceptions, consistent with our finding that the solutions to micromanagement most commonly mentioned in the reviewed articles were supervision entrustment and trainee empowerment.For clinical supervisors, it is sometimes difficult to know when a trainee is ready for unsupervised independent patient care, especially when the evidence is inconclusive, and the opinions of the supervisor and trainee differ [31].In such cases, the Entrustable Professional Activity (EPA) can help in making such decisions [32].EPAs are units of practice that medical trainees have to master and that supervisors must trust them to perform adequately before they complete their training.The EPA lists professional tasks and proficiencies at five levels: having limited knowledge, acting under close supervision, acting under supervision on call, acting independently, and supervising others [32].In terms of when clinical supervisors who micromanage will feel comfortable granting autonomy to a trainee, the use of the EPA-based assessment may be a reasonable solution.
Our review revealed that in the vast majority of studies, micromanagement was associated with individual supervisor factors, particularly behavioral and personality factors, when compared with trainee and environmental factors.Factors such as acute clinical context or lack of trainee clinical competency also were seen as influencing micromanagement behavior, but to a much lesser degree.This suggests that supervisor perceptions of trainee ineffectiveness should not justify micromanaging trainees, but rather highlight the need for scaffolding that equips the trainee to reach a prescribed level of competence.This finding is inconsistent, however, with that of Sterkenburg et al. [31], who investigated factors affecting supervisor entrustment of trainees.They found that entrustment was most influenced by trainee factors, followed by faculty and contextual factors.This perceptual and hierarchical discrepancy to micromanagement may be due to different interpretations of clinical supervision.Some supervisors believe the purpose of clinical supervision is to facilitate the delivery of services to patients and monitor trainee performance, which is termed as managerial supervision [33].Others see supervision as a vehicle for supporting the professional development of trainees [16].Having a mutually agreed purpose of clinical supervision may be one of the keys for reducing ambiguity.
The reviewed literature revealed a number of adverse consequences of micromanagement in clinical supervision, including trainees' educational loss and threats to their psychological and physical health, threats to the safety, efficiency and capacity for patient care, and organizational dysfunction.Importantly, in articles where trainees were quoted, they stressed a sense of helplessness [26].One of the most frequently mentioned consequences of micromanagement was organizational dysfunction, including high staff turnover, decreased job satisfaction, absenteeism, and the diminished enthusiasm of team members-all bringing about threats to the safety, efficiency, and capacity of patient care.Some articles suggested that micromanagement can temporarily increase productivity [34].This connection between micromanagement and organizational dysfunction is important, since in most cases organizational dysfunction is linked to a long-term downturn in productivity.
Overall, solutions to micromanagement in clinical supervision centered on the capacity of supervisors to entrust or empower trainees through encouragement and clear communication.More specifically, such solutions involved concrete efforts by supervisors to facilitate open communication with trainees, and organizational management that aims to both support quality supervision and balance clinical and educational goals.Other recommendations included leadership training for supervisors and measures that ensured supervisors promote trainees' clinical and communication competencies.Among these multiple solutions, supervisor entrustment and empowerment of trainees were most commonly mentioned (41.7%, n = 5).
Given our finding that in most studies, micromanagement was attributed to individual supervisor factors, it is no surprise that an important solution involves training and development initiatives for faculty.Promoting self-awareness is a logical starting point for gradual improvement in entrusting or empowering trainees.In addition, supervisors need to know about the demonstrated positive benefits of good clinical supervision, such as trainees' reduced stress and anxiety, increased resilience, and job satisfaction.Upskilling and increased quality of care also result from effective supervision, which is best provided in an open, supportive, trusted environment that facilitates discussion and reflection on clinical practice [16].It is also noteworthy that the organizational role can be facilitative when managing the adverse culture of micromanagement to ensure that patient care and educational goals are equally valued and emphasized.One method can optimize collaboration between an educational supervisor (who concerns educational development) and a clinical supervisor (who concerns clinical practice) to reduce the tension between the two important values [16].
This scoping review has several limitations: the sample of relevant articles we identified from academic databases is fairly small, although we searched eight databases.The sample size suggests that micromanagement in clinical supervision is an emerging research area, and points to the appropriateness of a scoping review as a starting point for more rigorous empirically-based research in coming years, such as a systematic reviews, in-depth qualitative analysis, empirical investigations, and cohort studies.From further empirical research, researchers and practitioners can gain a more precise picture of micromanagement in clinical supervision.Although our analysis was inevitably limited to publications written in English, it was noted that USA cases were overwhelmingly included, which resulted in a lack of an international perspective in our study.Future research efforts could incorporate a more inclusive international viewpoint.Additionally, research on supervision in the field of psychology and mental health (e.g.[35,36].), a field adjacent to health professions could further enrich our understanding and provide additional valuable insights into the dynamics of micromanagement.In addition, the conceptual features of reviewed articles could be evaluated through future research using the consultation exercise of scoping review methodology in order to identify current issues facing key practicing stakeholders [15].With the advent of a more enhanced evidence-based foundation, more precise and effective processes for managing and ameliorating the effects of micromanagement could be implemented.

Conclusion
In current literature on micromanagement in clinical supervision, researchers have conceptualized micromanagement, and discussed its reasons/influencing factors, consequences, and solutions.The ineffective and effective supervisory practices associated with micromanagement that we identified in this study have implications for clinical supervisors in health profession educational settings.Such knowledge, as well as insights about alternative supervisory practices, reasons/influencing factors, consequences, and suggested solutions, can be used to recognize, solve, and prevent the prevalent, and often unrecognized, manifestation of micromanagement.In addition, by including the perspectives from supervisors, trainees, organizations, and patients, the findings can be used by health professions educators to develop various approaches to training, learning, and healthcare that best represent the needs of all stakeholders.We hope this review offers a useful springboard for more targeted empirical work and academic discourse around this topic, which could improve the quality of clinical education and patient care.
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Fig. 1
Fig. 1 PRISMA flow diagram for a scoping review of micromanagement in clinical supervision

Fig. 2
Fig. 2 Summary diagrams on reasons/affecting factors, consequences, and possible solutions of micromanagement

Table 1
Inclusion and exclusion criteria

Table 2
Features of reviewed studies

Table 3
Summary of reviewed studies