Lost in the crucible of supportive clinical supervision: supervision is not therapy

Seeing things differently: Evaluating psychodynamically informed group clinical supervision for general hospital nurses

This paper reports the findings from the development of psychodynamically informed group supervision for 52 clinical leaders in nursing at a general NHS hospital over four years. The initiative was evaluated through a variety of methods, underpinned by action research. This paper is based on the findings generated by semi-structured interviews (n=24) and descriptive statistics of staff sickness and turnover.

The findings suggest that clinical supervision using a psychodynamically informed approach helps nurses acknowledge their feelings and see their work from a different perspective; builds confidence; provides support through a crisis and reduces their isolation in their role. Other findings suggest that, while having no impact on staff turnover, clinical supervision might reduce staff sickness. However, not all staff were comfortable with the experiential nature of clinical supervision and there was fragmented attendance at sessions. Embedding supervision into nursing practice remains a challenge; this paper offers an approach that has proved sustainable over four years.

Effectiveness of clinical supervision of physiotherapists: a survey

OBJECTIVES

Limited literature exists on the practice of clinical supervision (CS) of professional physiotherapists despite current Australian safety and quality health standards stating that CS is to be provided to all physiotherapists. The aim of the present study was to evaluate the effectiveness of CS of physiotherapists working in an Australian public health service.

METHODS

CS was measured using the allied health-specific 26-item modified Manchester Clinical Supervision Scale (MCSS-26). Subscales of the MCSS-26 were summed for three domain scores (normative, restorative and formative) and a total score was calculated, which was compared with the reported threshold score of 73 for effective supervision. Sixty registered physiotherapists (response rate 92%), working for a large metropolitan public health service, with six different site locations, completed the survey.

RESULTS

The mean (± s.d.) total MCSS-26 score was 71.0 ± 14.3 (95% confidence interval (CI) 67.4-74.6). Hospital site was the only variable that had a significant effect on total MCSS-26 score (P=0.005); there was no effect for supervisor or supervisee experience, or hospital setting (acute vs subacute). Physiotherapists scored a significantly lower mean percentage MCSS-26 score on the normative domain compared with the restorative domain (mean difference 7.8%; 95% CI 2.9-12.7; P=0.002) and the formative domain (mean difference 9.6%; 95% CI 6.3-13.0; P<0.001). Of the two subscales that form the normative domain, 'finding time' had a significantly lower mean percentage MCSS-26 score than 'importance/value of CS' (mean difference 35.4%; 95% CI 31.3-39.4; P<0.001).

CONCLUSIONS

Within this publicly funded physiotherapy department there was uncertainty about the effectiveness of CS, with more than half the physiotherapists rating their supervision as less than effective, suggesting there is opportunity for improvement in the practice of physiotherapy CS. Physiotherapists scored lowest in the normative domain, indicating that they found it difficult to find time for CS.

Changes in emotion work at interdisciplinary conferences following clinical supervision in a palliative outpatient ward

In this article, I describe changes in emotion work at weekly interdisciplinary conferences in a palliative( 1) outpatient ward following clinical supervision (CS). I conceive emotions as constantly negotiated in interaction, and I researched the similarity between how this is done during CS and at interdisciplinary conferences following CS. In this respect, CS is seen as a particular discursive practice for emotion work. The findings show how conferences following supervision become inspired by the "language game" in CS, initiating metaperspectives on the care and treatment of patients. These metaperspectives illuminate a dual aspect of care in the sense that it serves the needs not only of patients but also team members. I argue that this recognition captures one of the great challenges in palliative care, namely, to separate the carer's own needs and emotions from those of patients. I therefore conclude that CS enhances professional development and may prevent burnout in palliative care.

Group clinical supervision in pre-registration nurse training: the views of mental health nursing students

In 1994 the Department of Health recommended that nurses be introduced to the process of clinical supervision during pre-registration training. In response to this recommendation, the now defunct English National Board (ENB) stated that: "It will be a requirement that all students of pre-registration nursing programmes receive preparation in what to expect from clinical supervision" (ENB, 1995, p. 4). Despite the fact that no further guidance was issued there is an emerging body of literature exploring this area. This paper reports findings from the initial phase of a three-year prospective longitudinal study examining students' experiences of group clinical supervision undertaken as part of their pre-registration training. In this part of the study 32 mental health nursing students participated in focus groups in which they discussed their expectations of clinical supervision. Content analysis of the data produced five major categories: 'the nature of clinical supervision'; 'roles and responsibilities'; 'staying safe and doing no harm'; 'being in a group'; and 'being a student'. The findings suggest that the idea of supervision is attractive to students, although there are significant anxieties both about supervision in general and of group supervision in particular.

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.

Efficacy of clinical supervision: influence on job satisfaction, burnout and quality of care

AIM

This paper reports a study to determine how supervisees' backgrounds and surrounding infrastructure predict the efficacy of clinical supervision among Finnish nursing staff, their job satisfaction, levels of burnout and perceptions of the quality of care.

BACKGROUND

Several studies have described the effects of clinical supervision, but few have focused on evaluating it. Until recently, no studies have examined how clinical supervision evaluations are related to supervisees' backgrounds, surrounding infrastructure or respondents' levels of burnout, job satisfaction and perceptions of the quality of care.

METHODS

The survey involved supervisees completing a range of standardized and validated evaluation measures. The respondents were identified from 12 regional, central and university hospitals across Finland (n = 799). The data collection took place from October 2000 to February 2001.

FINDINGS

The evaluations varied statistically significantly and were associated with statistically significant variations in the respondents' backgrounds. Clinical supervision infrastructure was also strongly related to evaluation scores. Supervisees' age, education, gender, employment status, area of specialty, working hours, work experience and experience as a supervisor were statistically significant predictors for evaluations of the efficacy of clinical supervision. These evaluations of clinical supervision were also found to predict the respondents' job satisfaction, levels of burnout and assessments of good nursing.

CONCLUSION

Nursing staff, especially those who have over 10 years' work experience, work in general care, have a nursing diploma, are non-tenured, work part-time and work 24-hour rotating shifts can benefit from clinical supervision. However, resources need to be invested in supervisor education and nursing staff need to be encouraged to start working in both supervisor and supervisee roles because of the positive effects on job satisfaction and quality of care.

Group supervision in facilitating learning and teaching in mental health clinical placements: a case example of one student group

Clinical supervision has become an essential component in nursing practice. This paper explores the experiences of two small groups of Finnish Registered General Nurse students receiving supervision during a clinical placement in mental health care (N = 23). Both groups worked in similar clinical placements, with one group receiving group supervision, the other individual supervision. Students reported that group supervision was a positive experience and a good alternative to the traditional supervision they had received earlier. Group supervision allowed students to begin to address their fears and anxieties over their ability to deal with the unfamiliar emotional and psychological demands of practice. Eighteen students reported that the staff nurse mentor was most important in helping them better understand the core concepts and practice of nursing. All the students who thought that nurse teacher was important in this regard came from the group supervision group.

Clinical supervision: beginning the supervisory relationship

While much has been written on clinical supervision (CS) in the nursing literature, there appears to be minimal attention afforded to the supervisory relationship and in particular the early phases of this relationship. It is understood that the quality of the supervisory relationship has a significant contribution towards the efficacy of CS. In acknowledging the struggles in demonstrating the effectiveness of supervision it seems reasonable to turn attention towards the relationship between supervisor and supervisee. This article begins by providing an overview of the supervision literature concerned with the supervisory relationship. Following this, attention is focused on the commencement of this alliance by describing the processes and attributes needed to commence a supervisory relationship.A comprehensive template for establishing a supervision agreement is presented. However, it is suggested that this template does not have to be confined for use in this particular clinical context but may be applicable to a variety of nursing environments. It is proposed that such an agreement/contract facilitates healthy beginnings for the supervisory relationship and goes some way towards enhancing the trajectory of this alliance.

Cutting across boundaries: a case study using feminist praxis to understand the meanings of self-harm

Deliberate self-harm predominantly occurs in women under the age of 30 years. This qualitative case study using feminist methods explored the experiences of three women who each had a long history of self-harming behaviour. Psychoanalytical concepts are used to explore the meaning of the conflicts that these women experience. Emergent themes include: great expectations, I speak but no one hears, sexual naivety meets sexual violence, and redrawing the sexual map. This thematic analysis helps facilitate an insight into what these women are trying to communicate, and provides guidance for mental health professionals to more effectively respond to the challenges of working with women who self-harm.

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.

The impact of unrelieved patient suffering on palliative care nurses

AIM

to describe the impact of unrelieved patient suffering on nurses working with palliative care patients.

DESIGN

This was a qualitative descriptive design using semi-structured interviews.

SAMPLE

nine experienced palliative care nurses were interviewed.

RESULTS

nurses acknowledged that the term 'suffering' generally was not used in the workplace. The nurses identified that only a small group of patients died with suffering that could be classified as 'unrelieved' but that the impact of these patients' suffering on themselves was enormous. Nurses describe the impact in terms of perceptions of suffering (difficult situation), feelings (helplessness, distress, feelings of failure), bearing the burden (alcohol consumption, headaches) and effects on their relationship with family. The nurses identified several factors that increased the personal impact of unrelieved patient suffering. The most important strategy for ameliorating the impact of unrelieved patient suffering was informal support from work colleagues.

CONCLUSION

the nurses' stories indicate that the personal impact of unrelieved patient suffering could be reduced through acknowledgement of this suffering and better formal and informal support mechanisms.

John Heron's six-category intervention analysis: towards understanding interpersonal relations and progressing the delivery of clinical supervision for mental health nursing in the United Kingdom

AIMS

This paper provides a critique of how Heron's six-category intervention analysis framework has been adopted by nursing in the United Kingdom (UK) as a theoretical framework in nursing research and model for clinical supervision. From this, its merits as an analytic framework and model for clinical supervision in nursing are discussed.

BACKGROUND

Heron's six-category intervention analysis has been acknowledged as a means by which nursing could develop its therapeutic integrity. It has also been used as a theoretical framework in nursing research focusing on nurses' perceptions of their interpersonal style. More recently descriptions of this framework have been proposed as a structure for clinical supervision. However, its use as a theoretical framework to underpin research investigating the interpersonal skills of nurses and as a model of clinical supervision must firstly be scrutinized.

FINDINGS

Returning to Heron's original description and comparing this with its current adoption in the UK, misconceptions of this framework can be identified. Its value as an analytic tool investigating interpersonal relations in nursing has still to be evaluated. Furthermore, nursing's emphasis on certain intervention categories has undermined the potential potency of this framework and its contribution as a model for clinical supervision in nursing.

CONCLUSION

We argue that Heron's six-category intervention analysis as a framework to investigate the interpersonal competence of nurses, particularly mental health nurses, requires investigation. This, in turn, would provide an opportunity to challenge the framework's theoretical standpoint. In addition to its value as an analytic tool, all six categories of Heron's framework have equal relevance to its contribution in nursing as a supervision model.

Illuminative evaluation: evaluating clinical supervision on its performance rather than the applause

AIM(S) OF THE PAPER: This paper gives a description of illuminative evaluation and argues for its use in process-focused research investigating the reciprocal interpersonal interactions between clinical supervisors and their supervisees. Experiences from conducting an initial pilot study, which is a part of larger qualitative project concerned with individual clinical supervision in mental health nursing, are highlighted.

BACKGROUND

Research investigating fundamental process issues in clinical supervision and their influence on outcomes for nursing is uncommon. Previous work in this area has stopped short of exploring the supervisory relationship and illuminating the importance of this interpersonal process in the delivery of gains. At the heart of the present project are questions about which supervisor interventions facilitate and constrain the supervisee's use of individual clinical supervision.

METHOD

Data were collected using individual in-depth interviews, critical incident journals, session documents and audio recordings of supervision using illuminative evaluation and a case study approach.

FINDINGS

Supervisor interventions included taking the lead, suggesting an option, exploring the supervisee's work, reflecting back, conveying an understanding of client issues, being supportive and giving information. Using Heron's framework, catalytic, prescriptive, informative and supportive interventions were identified. Interestingly, informative interventions related mainly to the sharing of team policy issues and were derived from the clinical supervisor's agenda. Although undoubtedly relevant to the supervisee's practice, such organizationally focused information giving may be at odds with progressing the therapeutic integrity and professional development of the supervisee. Degenerative interventions were also illuminated.

CONCLUSIONS

Following the pilot study, it was concluded that the research approach known as illuminative evaluation using multiple case studies is an appropriate design to explore the supervisory process and the particular clinical supervisor and supervisee interactions which influence this. Potential outcomes from the supervisory experience will be contextualized with how mental health nurses engage in the supervisory process and the particular supervisor interventions delivered during supervision sessions.

Practice nurses and their 'lived experience' of clinical supervision

Increased workload in primary care and the advent of primary care groups means that practice nurses (PNs) are experiencing a profusion of changes. As a result, PNs have taken on board many new skills, and this has increased the demands and stresses made upon them. Accordingly, this study investigated 17 PNs' lived experiences of clinical supervision following a 4-day training programme. It adopted a hermeneutic, phenomenological method. Data were collected by means of semistructured interviews within a series of focus groups. The data from the focus groups underwent a thematic analysis, which induced an emerging theory comprising five key themes: (1) providing support (2) nurturing and growth (3) enhancing and enriching practice (4) encountering a new experience, and (5) engaging in intellectually challenging and demanding work. The findings indicated that the central theme of the PNs' experience of clinical supervision was that of 'providing support', in that, without the presence and application of support, the effectiveness of the other themes appears to be diminished. The findings additionally indicated a range of issues, discussed under the headings: practice, education, policy, and further research.

Cognitive therapy supervision as a framework for clinical supervision in nursing: using structure to guide discovery

Cognitive therapy supervision as a framework for clinical supervision in nursing: using structure to guide discovery Cognitive therapy has an undisputed evidence base upon which its clinical application flourishes. This approach is now a well-recognized and widely adopted method used in the treatment of a diversity of psychological problems. More recently, prominent innovators of this psychotherapy have devised a framework to guide the clinical supervision of cognitive therapists. In keeping with its therapeutic application, the cognitive therapy framework for supervision is focused, structured, educational and collaborative. It serves to enhance the therapeutic proficiency of the cognitive therapist. In contrast, the supervision models reported in the recent nursing literature are less precise in their mission and when evaluated their contribution to nursing is shown to be dubious. Following an overview of the supervision models commonly cited in the nursing literature, a more focused comment on the evaluative research concerning Proctor's three-function interactive model will be offered. It is suggested that the unconvincing research findings may be related to the conceptual muddle surrounding clinical supervision, and the expectation for clinical supervision to deliver more than an opportunity for the progression of our therapeutic integrity. From this, a cognitive therapy supervision framework is described and suggested by the authors as a structure from which supervisors can guide discovery.