Some benefits experienced by hospice nurses from group clinical supervision

Palliative care nurses' experiences of clinical supervision: a qualitative evidence synthesis

Background:

Clinical supervision provides support and facilitates professional and personal development.

Aim:

To identify and synthesise all available qualitative research on palliative care nurses' experiences of clinical supervision.

Methods:

Guided by the ‘enhancing transparency in reporting the synthesis of qualitative research’ (ENTREQ) statement, eight databases were searched using a systematic search strategy (Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, PsycINFO, Medline, Web of Science, ProQuest, Embase, Psychological and Behavioural Sciences). The findings of all included studies were analysed guided by Thomas and Harden's approach. Confidence in the review findings was determined guided by Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual).

Findings:

Nine qualitative studies were included in this synthesis and four analytic themes were identified: negative experiences and misunderstandings of clinical supervision; clinical supervision needs structure and clarity; supervisor needs to be a conductor and a producer; finding your ‘inner supervisor’.

Conclusion:

The review illuminates the benefits of clinical supervision as a renewal process for palliative care (PC) nurses, but also highlights the challenges in its provision. Organisations should provide designated time and opportunities for PC nurses to attend clinical supervision sessions during working hours.

Perspectives of specialists and family physicians in interprofessional teams in caring for patients with multimorbidity: a qualitative study

BACKGROUND

Patients with multimorbidity often require services across different health care settings, yet team processes among settings are rarely implemented. We explored perceptions of specialists and family physicians collaborating in a telemedicine interprofessional consultation for patients with multimorbidity to better understand the value of bringing physicians together across the boundaries of health care settings.

METHODS

This was a descriptive qualitative, interview-based study. Physicians who had previously participated in the Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (Telemedicine IMPACT Plus [TIP] Program) were invited to participate and asked to describe their experience of being a member of the program. Interviews were conducted from March to May 2016. We conducted an iterative and interpretive process using both individual and team analysis to identify themes.

RESULTS

There were 15 participants, 9 specialists and 6 family physicians. Three themes emerged in the analysis: creating new perspectives on care for patients with multimorbidity by sharing knowledge, skills and attitudes; the shift from a consultant model to an interprofessional team model (allowing a window into the community, extending discussions beyond the medical model and focusing on the patient's health in context); and opportunities for learners, including learning about interprofessional collaboration and gaining exposure to a real-world model for caring for people with multimorbidity in outpatient settings.

INTERPRETATION

Family physicians and specialists participating in a TIP Program believed the program improved their knowledge and skills, while also serving as an effective care delivery strategy. The findings also support that learners require more exposure to nontraditional consultant models in order to care for patients with multimorbidity effectively.

A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England

Background

Schwartz Center Rounds®(Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care.

Objectives

How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care.

Design

(1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation).

Setting

(1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey).

Participants

(1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings.

Results

(1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p < 0.05) in Rounds attenders (25% to 12%) compared with non-attenders (37% to 34%). (4 and 5) Rounds were described as interesting, engaging and supportive; four contextual layers explained the variation in Rounds implementation. We identified four stages of Rounds, ‘core’ and ‘adaptable’ components of Rounds fidelity, and nine context–mechanism–outcome configurations: (i) trust, emotional safety and containment and (ii) group interaction were prerequisites for creating (iii) a countercultural space in Rounds where staff could (iv) tell stories, (v) self-disclose their experiences to peers and (vi) role model vulnerability; (vii) provide important context for staff and patient behaviour; (viii) shining a spotlight on hidden staff and patient stories reduced isolation and enhanced support/teamwork; and (ix) staff learned through reflection resulting in ripple effects and outcomes. Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and reported changes in practice. The impact of Rounds is cumulative and we have identified the necessary conditions for Rounds to work.

Limitations

Rounds outcomes relied on self-report, fewer regular attenders were recruited than desired, and it was not possible to observe staff post Rounds.

Conclusion

Rounds offer unique support for staff and positively influence staff well-being, empathy and compassion for patients and colleagues.

Future work

The adaptation of Rounds to new contexts and to increase reach needs evaluation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Workplace learning through collaboration in primary healthcare: A BEME realist review of what works, for whom and in what circumstances: BEME Guide No. 46

BACKGROUND

Changes in healthcare practice toward more proactive clinical, organizational and interprofessional working require primary healthcare professionals to learn continuously from each other through collaboration. This systematic review uses realist methodology to consolidate knowledge on the characteristics of workplace learning (WPL) through collaboration by primary healthcare professionals.

METHODS

Following several scoping searches, five electronic bibliographic databases were searched from January 1990 to December 2015 for relevant gray and published literature written in English, French, German and Dutch. Reviewers worked in pairs to identify relevant articles. A set of statements, based on the findings of our scoping searches, was used as a coding tree to analyze the papers. Interpretation of the results was done in alternating pairs, discussed within the author group and triangulated with stakeholders' views.

RESULTS

Out of 6930 references, we included 42 publications that elucidated who, when, how and what primary healthcare professionals learn through collaboration. Papers were both qualitative and quantitative in design, and focused largely on WPL of collaborating general practitioners and nurses. No striking differences between different professionals within primary healthcare were noted. Professionals were often unaware of the learning that occurs through collaboration. WPL happened predominantly through informal discussions about patient cases and modeling for other professionals. Any professionals could both learn and facilitate others' learning. Outcomes were diverse, but contextualized knowledge seemed to be important.

DISCUSSION/CONCLUSIONS

Primary care professionals' WPL is multifaceted. Existing social constructivist and social cognitivist learning theories form a framework from which to interpret these findings. Primary care policy makers and managers should ensure that professionals have access to protected time, earmarked for learning. Time is required for reflection, to learn new ways of interaction and to develop new habits within clinical practice.

Perceptions of a clinical psychology support group for spinal injury

BACKGROUND

A service evaluation was performed exploring nurses' perceptions of a clinical psychology facilitated peer support group in a spinal injury rehabilitation setting.

AIMS

To determine whether staff found the meetings useful while, more broadly, to highlight the need to support and supervise nursing staff in psychological care appropriately.

METHOD

A questionnaire was developed and distributed to the 30 members of staff who worked on the ward. Seventeen questionnaires were returned (57%). Data was analysed using thematic analysis.

RESULTS

The meetings were viewed as a place to discuss issues, and a safe protected space to share stresses. Staff felt the meetings aided team cohesion and helped them share ideas and draw up clinical strategies. Meetings aided stress management and confidence building. Staff considered the meetings to increase their psychological awareness and understanding.

CONCLUSION

Staff involved in the acute care and rehabilitation of spinal injured patients are consistently exposed to highly demanding and stressful clinical environments. Support meetings where staff can discuss patient and ward issues are invaluable. Other clinical nursing areas would benefit from similar support systems.

Establishing clinical supervision in acute mental health inpatient units: acknowledging the challenges

After decades of discussion about clinical supervision and mental health nursing, the reality is that many acute mental health inpatient settings continue to struggle with the notion of clinical supervision and the implementation process. In this article we delineate the key elements of clinical supervision, explore practical and dynamic difficulties associated with clinical supervision and question whether too much is being asked of this one process, especially in acute inpatient settings. For many mental health nurses, existing practices offer many of the purported benefits of clinical supervision. Ultimately, unless clinical supervision is better understood and implemented effectively, it is unlikely to meet expectations. Clinical supervision should ultimately be defined by the nurses participating in it. This article contributes to current discussions regarding the purpose of clinical supervision, the realities of its implementation, and in particular considers the role of clinical supervision relative to existing professional support opportunities.

Introducing clinical supervision across Western Australian public mental health services

Retention and recruitment of the mental health nursing workforce is a critical issue in Australia and more specifically in Western Australia (WA), partly due to the isolation of the state. It has been suggested that these workforce issues might be minimized through the introduction of clinical supervision within WA mental health services, where, historically, it has been misunderstood and viewed with caution by mental health nurses. This may have been partly due to a lack of understanding of clinical supervision, its models, and its many benefits, due to a paucity of information delivered into initial nurse education programs. The aim of this pilot project is to explore and evaluate the introduction of clinical supervision in WA public mental health services. A quantitative approach informed the study and included the use of an information gathering survey initially, which was followed with evaluation questionnaires. The findings show that education can increase the uptake of clinical supervision. Further, the findings illustrate the importance of linking clinicians from all professional groups via a clinical supervision web-based database.

Critical care nurses' experiences of grief in an adult intensive care unit

AIM

This paper is a report a study of critical care nurses' experiences of grief and their coping mechanisms when a patient dies.

BACKGROUND

The goal of patients entering critical care is survival and recovery. However, despite application of advanced technologies and intensive nursing care, many patients do not survive their critical illness. Nurses experience death in their everyday work, exposing them to the emotional and physical repercussions of grief.

METHOD

This study adopted a Heideggerian phenomenological approach, interviewing eight critical care nurses. Data collection occurred in 2007/8. Interviews were transcribed verbatim and themes generated through Colaizzi's framework.

FINDINGS

Participants reported feelings of grief for patients they had cared for. The death of a patient was reported as being less traumatic if the participant had perceived the death to be a 'good death', incorporating expectedness and good nursing care. They described how a patient's death was more significant if it 'struck a chord', or if they had developed 'meaningful engagement' with the patient and relatives. They denied accessing formal support: however, informal conversations with colleagues were described as a means of coping. Participants exhibited signs of normalizing death and described how they disassociated themselves emotionally from dying patients.

CONCLUSION

There are many predisposing factors and circumstantial occurrences that shape both the nature of care of the dying and subsequent grief. Repeated exposure to death and grief may lead to occupational stress, and ultimately burn out. Emotional disengagement from caring for the dying may have an impact on the quality of care for both the dying patient and their family.

Emotional toil: psychosocial care in rural settings for patients with cancer

AIM

This paper is a report of a study to identify experienced rural nurses' perceptions of key issues related to the provision of effective psychosocial care for people with cancer in rural settings.

BACKGROUND

A cancer diagnosis has a major impact on psychological and emotional wellbeing, and psychosocial support provided by nurses is an integral part of ensuring that people with cancer have positive outcomes. Although, ideally, people with cancer should be managed in specialist settings, significant numbers are cared for in rural areas.

METHODS

Using a qualitative descriptive approach, three focus groups were conducted in 2005 with 19 nurses in three hospitals in rural Victoria, Australia.

FINDINGS

Participants indicated that a key issue in providing psychosocial care to patients with cancer in the rural setting was their own 'emotional toil'. This Global Theme encapsulated three Organizing Themes- task vs. care, dual relationships and supportive networks--reflective of the unique nature of the rural environment. Nurses in rural Australia are multi-skilled generalists and they provide care to patients with cancer without necessarily having specialist knowledge or skill. The fatigue and emotional exhaustion that the nurses described often has a major impact on their own well-being.

CONCLUSION

In the rural context, it is proposed that clinical supervision may be an important strategy to support clinicians who face emotional exhaustion as part of their cancer nursing role.

Wicked spell or magic bullet? A review of the clinical supervision literature 2001-2007

Clinical supervision has become an established part of nursing. Implemented in various different ways it has attracted attention from the research, educator and practice communities. The literature reported and analysed in this paper describes work that may benefit professional practice but there continue to be questions about application and method. Two new messages arise from the literature. The first underscores the responsibility of health care organisations to sustain and develop clinical supervision and the second points to the potential benefit that clinical supervision may have on patient outcomes.

Group-format clinical supervision for hospice nurses

This paper discusses the aspects of a small research study, which used mixed research methods. The study concerned group-format supervision as a means of helping five hospice nurses, four women and one man, discuss their work experiences. An aim of the study was to understand something of the professional work of hospice nurses and how they might best be supported. Ethical considerations and some benefits derived by group members from clinical supervision are summarized in the context. The research method entailed 12 sessions of group-format clinical supervision. The discussion explores the forming, management and dynamics of a small clinical supervision group. Hospice work is emotionally demanding of nurses. Nurses throughout this small study thought over issues concerning serious illness, death and bereavement, as well as working together as a supervision group. Group-format supervision is potentially helpful to nurses examining professional practice. However, group work can be as challenging to participants as it is helpful. The discussion concludes with an appraisal of the potential gains for nurses from clinical supervision in group-format. This paper proposes that supervision groups could help hospice nurses to identify and explore issues related to professional practice. Adequate preparation of nurses, organizational support and the competency of group facilitators should be considered critical to safe and effective management of professional groups.

Clinical supervision: what do we know and what do we need to know? A review and commentary

AIMS

This study is addressed to nurses but the issues are of equal concern to both midwives and health visitors. Clinical supervision ideally both challenges nurses as well as help their practice. There is need to identify critical elements that help professional practice and understand more clearly the changing nature of supervisory relationships.

BACKGROUND

Clinical supervision in nursing is over a decade old in the UK and yet emerging nursing literature suggests that many ideas remain unfamiliar to nursing practice. The resistance shown by nurse towards clinical supervising remains perplexing. Moreover, ideas concerning clinical supervision have been applied without a substantive evidence base.

METHODS

The discussion draws on varied ideas concerning supervision, including those outside of nursing, to ask what do we know and still need to know about clinical supervision. This study suggests that, a single approach to clinical supervision could be unhelpful to nursing.

FINDINGS AND CONCLUSION

Nursing knowledge concerning many aspects of clinical supervision is increasing because of research. Much of the literature suggests that clinical supervision is scholarly activity requiring much the same attention to relationships as the therapeutic activities it supports. This discussion concludes with the idea that clinical supervision might work at its best as a quiet activity allowing nurses to think about nursing work in ways that suit individual learning styles.

Symptoms suffered by life-limited children that cause anxiety to UK children’s hospice staff

BACKGROUND

Very little is published about the symptom profile of children with life-limiting illnesses other than cancer.

METHOD

A postal questionnaire was sent to children's hospice staff who were asked to identify symptoms experienced by life-limited children which caused them anxiety.

RESULTS

Staff in 23 hospices were sent questionnaires. Twenty-eight questionnaires were returned from 10 doctors and 18 nurses. Just under half of the hospices contacted were represented. The staff were very experienced but had significant anxieties about treating some of their patients.

AIMS

This study aimed to identify the symptoms which cause anxiety to staff working in children's hospices. More than 70% of all staff groups felt that identifying the symptom correctly caused more anxiety than treating identified symptoms. For doctors the top five symptom problems were, seizure control, spasms, pain assessment, unidentified distress and vomiting. For nurses the main concerns were the non-verbal child in distress, psychiatric or psychological problems, assessing pain, seizures, pain management, vomiting.

CONCLUSIONS

Doctors and nurses perceive seizures, pain management, and vomiting as the most troublesome symptoms for children with life-limiting conditions. Further research is needed into symptom management in this area.

Patients with haematological malignancies show a restricted body image focusing on function and emotion

The diagnosis of cancer threatens the psychological and bodily integrity. Based on this assumption, we aimed to explore how newly diagnosed patients cope with special regard to the body image (BI). In total, 40 patients (32 haematological malignancies) were assessed by questionnaires on mood, complaints, self-regulation and quality of life (QOL). The BI was assessed by the 'Body Grid' which reveals the constructs patients choose to characterize the body. The constructs were categorized using a model of six predefined categories comprising: emotion, control, activity, strength, function and appearance. Tinnitus sufferers and medical students served as comparison groups. Cancer patients showed significantly more anxious depression and a significantly lower QOL than controls. Their BI was restricted, focusing the functional status of body organs (e.g. opposing healthy vs. ill organs) as well as emotional aspects (e.g. trust vs. fear). The data convey fundamental psychological distress in newly diagnosed cancer patients. Restriction of BI and use of functional constructs may help to buffer the threat to body integrity. The emotional constructs reflect the existential impact. The data give a clear indication for the need for early psychosocial support which should aim at stabilizing the psychological and bodily integrity of the patient.

The cultural realities of clinical supervision in an acute inpatient mental health setting

In this paper, the cultural realities of clinical supervision (CS) in acute inpatient mental health settings are explored using an ethnographic approach. Findings suggest that there is a verbal acceptance of CS by mental health nurses but a cultural belief that it has limited experiential value and, thus, a cautious attitude towards its adoption is in practice. This may, in part, be attributable to many nurses believing that they are already undertaking CS, although the informal supervision described does not fit with established definitions of formal supervision. The language used by nurses demonstrates an understanding and appreciation of the benefits of clinical supervision. However, the belief that existing structures inherent to nursing practice already convey these benefits may contribute to the culture of passive resistance to clinical supervision revealed by the findings. This study contributes to current discussions regarding the purpose of CS, the realities of its implementation, and its role relative to existing professional support opportunities.