Clinical supervision as an emancipatory process: avoiding inappropriate intent

Clinical supervision for transition to advanced practice

PURPOSE

This reflective paper offers a conceptual framework of clinical supervision that assists supervisors to create supportive relationships necessary for advanced practice development.

CONCLUSIONS

Combining established concepts of clinical supervision with systems psychodynamics enhances the supervisory experience. It is useful to supervisors to understand role transition as it sensitizes them to what their supervisees experience.

PRACTICE IMPLICATIONS

Nurses require support in role transition, especially when the systems into which they are introduced can struggle with new advanced roles. This framework offers a broadened lens that allows for the richness and complexities that go with the development of advanced practice to be explored and better understood.

Does clinical supervision promote medical-surgical nurses' well-being at work? A quasi-experimental 4-year follow-up study

AIM

The aim of the present paper is to report results of a quasi-experimental study exploring the effects of clinical supervision (CS) on the development of medical-surgical nurses' well-being at work over a 4-year period.

BACKGROUND

Effective workplace interventions are needed to prevent stress and burnout. More robust scientific evidence is needed to confirm the restorative effects of CS in nursing.

METHODS

A questionnaire survey on the perceptions of work and health was conducted in 2003 and 2007 on 14 units of a Finnish university hospital where 19 CS group processes had been completed between 2004 and 2007.

RESULTS

Improvement in job resources as well as reduction in professional inefficacy and psychological distress were found among nurses who received effective CS (n = 41), but were not present among the nurses who found their CS less effective (n = 43) or who did not attend CS (n = 82).

CONCLUSIONS

The results provide robust evidence for the positive effects of CS on medical-surgical nurses' well-being at work.

IMPLICATIONS FOR NURSING MANAGEMENT

Stress is a developmental challenge in the professional growth of individual nurses. One option for management to sustain nurses' well-being at work is to develop a learning organization in the workplace making use of CS.

Re-searching for therapy: the ethics of using what we are skilled in

Narrative inquiry as a qualitative research method appears to be growing in popularity among mental health nurses. This paper argues that there are a number of parallels between narrative inquiry and psychotherapy, and mental health nurses familiar with the practice of therapeutic engagement need to be mindful of these when using this approach to research. The symbiotic relationship between those engaged in narrative inquiry and those engaged in psychotherapeutic practice is explored in order to provide greater understanding of some of the ethical issues involved and how new researchers, supervisors and practitioners might better respond to the complexities inherent in using narrative inquiry which may itself be therapeutic. Our focus for this paper is the tensions experienced by the mental health nurse while working as a researcher when the research encounter provides a trigger that would normally elicit a therapeutic response for both participant and nurse. Using a selection of psychoanalytic theories and principles this paper explores the relationship between the processes of psychotherapy and narrative inquiry. This discussion paper is based on the authors' own research experiences of using narrative inquiry to explore a number of sensitive issues and many years of supervisory relationships with students and practitioners alike.

Interconnectedness in Nursing

Aim: Interconnectedness will be clarified and defined by providing a description and context and take an important step toward increasing use in nursing literature and research. Background: The literature is limited by focusing on relationships between people, but connection can be physical as with physics or spiritual by reflecting a higher power or purpose. Thorough examination will increase understanding of interconnectedness in nursing. Methods: Chinn and Kramer's method for creating conceptual meaning includes definitions, visual images, popular/classical literature, music, poetry, and professional research across many disciplines. Findings: Interconnectedness reflects that people and the universe are connected in a powerful way. Its essential meaning reflects that regardless of the worldly barriers of politics, religion, or culture, people can share in a universal reciprocity of love and responsibility. Conclusion: Nursing maintains the values of compassion, responsibility, holism, and to greater meaning in experiences, and interconnectedness will likely have increased significance in nursing.

Clinical supervision: The way forward? A review of the literature

A discussion of clinical supervision to enhance existing support structures such as preceptorship and mentorship to positively influence the recruitment and retention of newly graduate nurses provides the main focus for this paper. The nursing literature provides evidence for alternative but equally worthy perspectives on clinical supervision. Essential to the successful practice of clinical supervision is the need to ascertain whether it is simply a system to ensure an effective workforce or one that will empower nurses to realise their vision of nursing.

The Integration of Clinical and Managerial Supervision: A Critical Literature Review

The introduction of a new development review process, the Knowledge and Skills Framework (KSF), has placed a greater demand on occupational therapists within the health service to be more accountable for practice. It has been proposed that the KSF may provide a useful structure for supervision in order to ensure continual development. Therefore, this literature review looked at the appropriateness of addressing both clinical and managerial issues within the supervisory process.

The results indicate that despite many professions being unsure of how best to deliver supervision, there is a common understanding that a structure combining clinical and managerial supervision, such as the KSF, may be useful. It is, however, recommended that the roles of appraiser and supervisor remain separate, because many researchers found conflict within this duality of role as having an impact upon the effectiveness of supervision. It is also recommended that further research be undertaken in order to evaluate formally the effectiveness of integrating the KSF into supervision.

Community mental health nurses speak out: the critical relationship between emotional wellbeing and satisfying professional practice

The article reports on selected findings of a research study concerning emotional wellbeing and professional nursing practice (Rose 2002). It highlights the relationship between community mental health nurses' and emotional wellbeing, and their capacity to provide satisfying professional nursing practice (Rose 2002). The notion of emotional wellbeing, factors that impacted upon the participants' emotional wellbeing, and the relationship of emotional wellbeing to professional practice were revealed in the study. These findings were based on a qualitative critical feminist research inquiry and specifically, interviews with five women community mental health nurses in Australia. Whilst complex, emotional wellbeing was found to be both implicitly and explicitly linked to the participants intertwined personal and professional experiences. Four key components were identified: the nebulous notion; the stress relationship; the mind, body, spirit connection; and, inner sense of balance. In terms of emotional wellbeing and professional practice, three themes were revealed. These were: being able to speak out (or not); being autonomous (or not) and being satisfied (or not). The authors argue that the emotional wellbeing of nurses working in community mental health settings is critical to satisfying professional practice. Furthermore nursing work involves emotional work which impacts on one's emotional wellbeing and emotional wellbeing is integrally linked to professional practice. It is recommended that health organisations must be pro-active in addressing the emotional needs of nurses to ensure the delivery of health care that is aligned to professional practice. This approach will ensure nurses will feel more recognised and validated in terms of their nursing practice.

Clinical learning environments for student nurses: key indices from two studies compared over a 25 year period

In 1978, a longitudinal study commenced in England to illuminate criteria for the evaluation of hospital wards as clinical learning environments for student nurses. It derived measures to quantify the clinical learning experienced by 71 students in three cohorts in three training hospitals over their entire programme. In 2003, a second study, based in one English School of Health Studies, using clinical placements in three NHS trusts, employed a retrospective, cross-sectional, analytic survey design with anonymised, self-completion questionnaires, to map the clinical learning of 272 students as part of a quality assurance and enhancement initiative. This paper explores changes over time by comparing data based on five key indices, devised in the first study and revisited in the second. Concepts of clinical learning and supervision are reviewed as part of this changing context and background together with limitations implicit in the comparison. The findings suggest an average 20% improvement in the quality of hospital based clinical learning environments over a 25 year period, based mainly on trained staff personally supervising students more extensively, testing their theoretical knowledge more frequently and spending more time performing practical procedures with them. However, unacceptable variations in clinical learning opportunities persist for some students.

The reality of practice development for nurses working in an inpatient service for people with severe and enduring mental health problems

Nursing practice development is a growing priority for the British National Health Service. However, the nature of practice development remains poorly articulated. Despite the growing number of papers on practice development in nursing, there is insufficient guidance in the literature for the practical day-to-day management of the role, particularly in the inpatient environment. This paper explores the tensions experienced by practitioners engaged in practice development within a service for people mainly with a diagnosis of psychosis. The entrenched culture of the environment is described, which was resistant to change therefore did not easily embrace practice development. Within such a culture it is important to balance effective management with team development and support. Although this balance is essential for positive change, it is the maintenance of the balance that often leads to the tensions experienced by practice development practitioners. The paper describes numerous tensions including the competing agendas, influencing 'hearts and minds' rather than forcing change and working where people are at. Each tension is explored alongside possible survival strategies. The material presented aims to be realistic and although it may not be generalizable to other settings and staff groups, the authors hope to stimulate debate about similar or contrasting experiences of practice development.

An audit of clinical supervision in primary care

This article reports on an audit of clinical supervision in one primary care trust (PCT). Data were collected by telephone interviews with 44 respondents from a range of professions occupying different clinical and managerial grades in the organization. Clinical supervision was varied both in terms of its availability and management between different professional groups and teams reflecting, in part, differing levels of motivation towards supporting clinical supervision by individual practitioners and managers as well as a perceived lack of trust leadership. Respondents also reported several potential and actual benefits of clinical supervision, including the improvement and standardization of practice and the facilitation of learning and professional development, although there was no consensus regarding the most appropriate format (e.g. individual, group or team) or structure (e.g. uni-professional or multi-professional) for clinical supervision. It was widely agreed that the introduction of mechanisms for monitoring both the process and outcomes of supervision, greater protection of time allocated for supervision and more training opportunities to increase the skill and number of available supervisors were needed.

Reflective practice and clinical supervision: an interprofessional perspective

BACKGROUND

In the United Kingdom, the drive to encourage reflective practice through clinical supervision, as a means of ensuring quality of provision in nursing and other health care professions, is now well-embedded, not only in policy but also in practice. However, debate and critique of these concepts is limited.

AIM

The aim of this paper is to draw on research, conducted with undergraduate occupational therapy students and qualified physiotherapists, in order to contribute to the debate about the functions of clinical supervision and reflective practice in nursing and other health care professions.

DISCUSSION

Upholding the notion that clinical supervision has the potential to constitute a form of surveillance, we counter the assumption that it is inevitably confessional in nature. A social constructionist perspective is used to illustrate how clinical supervision might involve a complex interplay of factors that dispel notions of predictability, control and rationality.

CONCLUSION

Despite acknowledging tensions, we argue that clinical supervision is both necessary and beneficial. It can be advantageous to individual practitioners and professional groups in enhancing practice and accountability, and promoting professional development.

Narrating practice: reflective accounts and the textual construction of reality

BACKGROUND

Two approaches dominate current thinking in health and welfare: evidence-based practice and reflective practice. Whilst there is debate about the merits of evidence-based practice, reflective practice is generally accepted with critical debate as an important educational tool. Where critique does exist it tends to adopt a Foucauldian approach, focusing on the surveillance and self-regulatory aspects of reflective practice.

AIM

This article acknowledges the critical purchase on the concept of reflective practice offered by Foucauldian approaches but argues that microsociological and discourse analytic approaches can further illuminate the subject and thus serve as a complement to them.

METHODS

The claims of proponents of reflective practice are explored, in opposition to the technical-rational approach of evidence-based practice.

FINDINGS

Reflective practice tends to adopt a naive or romantic realist position and fails to acknowledge the ways in which reflective accounts construct the world of practice.

CONCLUSIONS

Microsociological approaches can help us to understand reflective accounts as examples of case-talk, constructed in a narrative form in the same way as case records and presentations.

Development of a group model of clinical supervision to meet the needs of a community mental health nursing team

Clinical supervision is an important tool in the development of quality nursing care. It involves a process of reflection upon practice, the aim of which is to improve clinical practices and hence improve patient outcomes. The term 'clinical supervision' is itself problematic in that it implies an hierarchical, rather than a nurse-centred and reflective, process. In addition there are a variety of models of supervision which range from the purely managerial to the clinical. This gives rise to confusion and in some cases suspicion, in clinicians. This paper reports on the development, implementation and evaluation of a group model of clinical supervision developed by a small team of mental health nurses in a community mental health setting. This team recognised the need for a formal clinical supervision model but was unsure as to the model which best suited their practice situation and needs. Through collaboration with a university department of nursing, this group developed its own model of group clinical supervision. This paper reports on the development of the model and its evaluation. The model was developed with a small team of community nurses and hence may not be applicable to other teams and other settings. However, the methods described may be useful as a guide to other nurses who wish to plan, implement and evaluate a model of clinical supervision in their workplace.

Peer supervision: an experimental scheme for nurse lecturers

This paper reports on the implementation of a scheme of peer supervision in a team of mental health nursing lecturers working within a university setting. The rationale for the introduction of this scheme was the implementation of clinical supervision in nursing nationally and the role nurse education can play in this. Supervision is advocated as a way of providing education, support and quality checks for lecturers involved in supervising students. The peer supervision scheme is described and the experience of the lecturers involved discussed. The authors stress the value of this innovation to their professional lives and promote it as a good way of contributing to the implementation of clinical supervision in mental health nursing.

Getting evidence into practice: the meaning of 'context'

AIM OF PAPER

This paper presents the findings of a concept analysis of 'context' in relation to the successful implementation of evidence into practice.

BACKGROUND

In 1998, a conceptual framework was developed that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice [Kitson A., Harvey G. & McCormack B. (1998) Quality in Health Care 7, 149]. One of the key elements of the framework was 'context', that is, the setting in which evidence is implemented. It was proposed that key factors in the context of health care practice had a significant impact on the implementation and uptake of evidence. As part of the on-going development and refinement of the framework, the elements within it have undergone a concept analysis in order to provide some theoretical and conceptual rigour to its content.

METHODS

Morse's [Morse J.M. (1995) Advances in Nursing Science 17, 31; Morse J.M., Hupcey J.E. & Mitcham C. (1996) Scholarly Inquiry for Nursing Practice. An International Journal 10, 253] approach to concept analysis was used as a framework to review semi-nal texts critically and the supporting research literature in order to establish the conceptual clarity and maturity of 'context' in relation to its importance in the implementation of evidence-based practice.

FINDINGS

Characteristics of the concept of context in terms of organizational culture, leadership and measurement are outlined. A main finding is that context specifically means 'the setting in which practice takes place', but that the term itself does little to reflect the complexity of the concept. Whilst the themes of culture and leadership are central characteristics of the concept, the theme of 'measurement' is better articulated through the broader term of 'evaluation'.

CONCLUSIONS

There is inconsistency in the use of the term and this has an impact on claims of its importance. The concept of context lacks clarity because of the many issues that impact on the way it is characterized. Additionally, there is limited understanding of the consequences of working with different contexts. Thus, the implications of using context as a variable in research studies exploring research implementation are as yet largely unknown. The concept of context is partially developed but in need of further delineation and comparison.

Reflective practice and clinical supervision: meticulous rituals of the confessional

BACKGROUND

Reflective practice and clinical supervision are progressively asserting hegemony upon nursing practice with claims of emancipation and empowerment. However, this is being achieved in an environment where there is little critical debate about the assumptions on which these practices are based.

AIM

This paper sets out to challenge the basis upon which reflective practice and clinical supervision are promoted within nursing discourse by employing Michel Foucault's (1982) concept of governmentality. Theme. A broad Foucauldian perspective is used to demonstrate how the technologies of reflective practice and clinical supervision have been accommodated within modern forms of government. These technologies are consistent with the flattened hierarchies and increasing dispersal of practitioners in contemporary health care. In this context reflective practice and clinical supervision can be shown to function in two independent but interrelated ways. First as modes of surveillance disciplining the activity of professionals. Second, as "confessional" practices that work to produce particular identities--autonomous and self-regulating.