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

'What is it we are trying to achieve here'? Community maternal and child health nurses and clinical supervision: A qualitative descriptive study

AIMS

To explore clinical supervision practice by Victorian Maternal and Child Health nurses, identify the self-reported supervision needs of nurses and the facilitators and barriers to meeting those needs.

BACKGROUND

Community-based Maternal and Child Health nurses have responsibilities for the safety and wellbeing of children and specific clinical support needs. Clinical supervision has the potential to support nurses' clinical practice and reflective skills; however, little is known internationally about child and family health nurses' supervision practices.

DESIGN

Qualitative descriptive study.

METHODS

Twenty-three semi-structured interviews were conducted between October and December 2021 with nurses, managers and supervisors across metropolitan, regional/rural areas of Victoria, Australia. Inductive thematic analysis was applied to the data. The Consolidated Criteria for Reporting Qualitative Research guided this study.

RESULTS

Three main themes, with subthemes were generated; 'Understand what we do', 'It's the gathering of the nurses' and 'Bringing a case'. A lack of agreed purpose, aims and varied understandings of clinical supervision contributed to suboptimal clinical supervision. Although participants agreed about the importance of clinical supervision, the perceived benefits were inconsistently realized.

CONCLUSIONS

This study points to a need for greater organizational awareness of the conditions and leadership needed to build reflective skills and culture in community-based child and family nursing.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research has guided this study.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution in the conduct of this study.

IMPACT

A stronger focus is needed to build reflective culture and skill in child and family nursing. Areas for improving child and family nurses' use of clinical supervision have been identified. This study can inform nurse education, policy and service leaders, to strengthen clinical supervision in child and family nursing contexts.

'Barriers to overcoming the barriers': A scoping review exploring 30 years of clinical supervision literature

Aims/Questions

To explore the barriers and facilitators to nurses accessing clinical supervision; explore the barriers and facilitators to organizations implementing clinical supervision and capture what skills nurses require to facilitate clinical supervision.

Design

Scoping review of peer‐reviewed research and grey literature.

Data sources

CINAHL, Medline, PsychINFO and Scopus were searched for relevant papers published between 1990 and 2020. Google, Google Scholar, OpenGrey & EThOS were used to search for grey literature.

Review Methods

PRISMA‐ScR guidelines were used during the literature review process. Eighty‐seven papers were included, and data were extracted from each paper using a standardized form. Data synthesis was undertaken using Seidel's analytical framework.

Results

Five themes were identified: Definitions and Models, (Mis) Trust and the Language of Supervision, Alternative Parallel Forums and Support Mechanisms, Time and Cost and Skills required.

Conclusion

Since its inception in the 1990s, clinical supervision has long been regarded as a supportive platform for nurses to reflect on and develop their practice. However, this review highlights that despite an awareness of the skills required for nurses to undertake clinical supervision, and the facilitators for nurses to access and organizations to implement clinical supervision, there have been persistent barriers to implementation. This review identifies these persistent factors as ‘barriers to overcoming the barriers' in the clinical supervision landscape. These require critical consideration to contribute towards moving clinical supervision forward in the spirit of its original intentions.

Impact

This review progresses the debate on clinical supervision through critically analysing the barriers to overcoming the barriers. To this end, the review is designed to stimulate critical discussions amongst nurses in different clinical spaces and key stakeholders such as policy makers and regulatory bodies for the nursing profession.

Factors influencing adequate and effective clinical supervision for inpatient mental health nurses' personal and professional development: An integrative review

WHAT IS KNOWN ON THE SUBJECT

CS was developed to give healthcare professionals a space to reflect, problem solve and recognise their own practice. It is different from managerial supervision as it is for the benefit of the individual staff member's personal and professional development firstly, but can potentially benefit the quality of care delivered by the organisation. There have been a range of problems associated with inpatient mental health nurses' engagement in CS and in experiencing the benefits of CS. This is concerning for the delivery of high quality care and the recruitment and retention of inpatient mental health nurses.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

This paper explores and identifies factors influencing adequate and effective CS for inpatient mental health nurses' personal and professional development. It identifies 6 themes incorporating enablers and barriers for inpatient mental health nurses' CS which lead to practice recommendations for improvement.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This paper advocates a needs analysis to improve access to CS for inpatient mental health nurses. This review specifically adds further knowledge relating to inpatient mental health nurses' engagement with CS which the application of the needs analysis could influence.

ABSTRACT

Introduction Clinical supervision (CS) has been recognized as a reflective mechanism in inpatient mental health nursing practice; however, it remains unclear what adequate and effective supervision entails for inpatient mental health nurses. Aim To explore factors which influence adequate and effective clinical supervision for inpatient mental health nurses' personal and professional development. Method Whittemore and Knafl's model for ensuring rigour was utilized. This included stages to address problem identification, literature searching, data evaluation, data analysis and presentation. Seven electronic databases were searched with hand searching/Internet searching. Fourteen retrieved articles were selected and appraised using the Mixed Method Appraisal Tool (MMAT). The data extracted from the papers were analysed thematically. Results The review synthesis resulted in identifying six themes: (a) what makes CS effective; (b) reflection; (c) the facilitation of professional identity and knowledge through CS; (d) participation; (e) knowledge and understanding of CS; and (f) the facilitation of personal awareness and coping. Discussion This review adds further knowledge on the identification of effective CS for inpatient mental health nurses as a defined occupational healthcare group. Implications for practice A suggested needs analysis is presented to improve access to CS options with the aim of promoting effective CS and increased engagement.

Burning out physical and emotional fatigue: Evaluating the effects of a programme aimed at reducing burnout among mental health nurses

Burnout is a common problem among mental health nurses. High levels of burnout result in job dissatisfaction, rapid turnover of staff, physical and psychological discomfort, and a reduction in the quality of patient care. While there is an abundance of research relating to burnout per se, research regarding the impact of burnout prevention programmes is lacking. This study aimed to measure the effects of a burnout prevention programme on mental health nurses working in Saudi Arabia (SA). A quasi-experimental design was used to test the effectiveness of a two-day burnout prevention workshop. The sample consisted of an intervention group (n = 154) and a control group (n = 142). Data collected using the Maslach Burnout Inventory (MBI) measured the effects of the workshop at 1-, 3-, and 6-month intervals after completion of the programme. Data were analysed using the latest version of SPSS. Means, standard deviations, frequencies, and percentages were used to describe the sample and levels of burnout. A t-test, ANOVA, multiple linear regression, and chi-squared were used to measure the effect of the workshop before and at the three time points after exposure. Findings indicate the programme was effective with a significant reduction being reported 1 month after the intervention. However, although not returning to baseline scores, burnout scores had increased at 6 months. In conclusion, while the overall efficacy of the burnout reduction programme is evident, mental health nurses would benefit from having opportunity to use some of the strategies on a regular basis.

Staff experiences and perceptions of working with in-patients who are suicidal: qualitative analysis

BackgroundSuicidal behaviour is frequent in psychiatric in-patients and much staff time and resources are devoted to assessing and managing suicide risk. However, little is known about staff experiences of working with in-patients who are suicidal.AimsTo investigate staff experiences of working with in-patients who are suicidal.MethodQualitative study guided by thematic analysis of semi-structured interviews with mental health staff with experience of psychiatric in-patient care.ResultsTwenty staff participated. All had encountered in-patient suicide deaths or attempts. Three key themes were identified: (a) experiences of suicidality, (b) conceptualising suicidality and (c) talking about suicide.ConclusionsSuicidal behaviour in psychiatric wards has a large impact on staff feelings, practice and behaviour. Staff felt inadequately equipped to deal with such behaviours, with detrimental consequences for patients and themselves. Organisational support is lacking. Training and support should extend beyond risk assessment to improving staff skills in developing therapeutic interactions with in-patients who are suicidal.

Nursing and health-care assistant experience of supervision in a medium secure psychiatric service for women: implications for service development

In secure psychiatric services where the potential for 'burnout' by nurses is high, clinical supervision is viewed as a key to reflective practice to support staff in stressful working environments. Barriers to the uptake of clinical supervision in such service settings are personal and organizational. The study was prompted by the need to evaluate the effectiveness of supervision for registered nurses and health-care assistants (HCAs) and a desire to use survey findings to improve the quality and uptake of supervision. The study examined the perceived benefits, the best practice elements and the practical aspects of clinical supervision including how to improve practice. An approximate uptake of clinical supervision by 50% of staff confirmed previous findings; that HCAs were significantly less likely to engage in supervision and less likely to perceive benefit from it. Initiatives to address the training and managerial obstacles to the provision of formal supervision are described.

Do structured arrangements for multidisciplinary peer group supervision make a difference for allied health professional outcomes?

Peer group supervision, particularly in multidisciplinary formats, presents a potential means of providing professional support, and specifically clinical supervision, for allied health professionals. Debate exists regarding the extent to which the activities of these groups should be formalized. Results drawn from an evaluation of a large-scale peer group supervision initiative are described. Analysis of 192 responses from professionals involved in peer groups indicates that participants in groups that used formal documentation – which adopted the tools provided in training, and particularly those that used formal evaluation of their groups – rated their groups as having better processes and greater impact. Interestingly, multidisciplinary peer groups were rated as having similar impacts, processes, and purposes as the more homogenous single-discipline groups. It is concluded that the implementation of formal arrangements enhances the processes and outcomes of peer groups implemented for professional support and clinical supervision. Multidisciplinary membership of such groups is perceived as equally beneficial as single-discipline groups.

Examining clinical supervision as a mechanism for changes in practice: a research protocol

AIM

This paper describes the research protocol for a study exploring if and how clinical supervision facilitates change in practice relating to psychosocial aspects of care for Health Professionals, who have been trained to deliver a psychosocial intervention to adults with cancer.

BACKGROUND

There is a recognized need to implement care that is in line with clinical practice guidelines for the psychosocial care of adults with cancer. Clinical supervision is recommended as a means to support Health Professionals in providing the recommended psychosocial care.

DESIGN

A qualitative design embedded within an experimental, stepped wedge randomized control trial.

METHODS

The study will use discourse analysis to analyse audio-recorded data collected in clinical supervision sessions that are being delivered as one element of a large randomized control trial. The sessions will be attended primarily by nurses, but including physiotherapists, radiation therapists, occupational therapists. The Health Professionals are participants in a randomized control trial designed to reduce anxiety and depression of distressed adults with cancer. The sessions will be facilitated by psychiatrists experienced in psycho-oncology and the provision of clinical supervision.

DISCUSSION

The proposed research is designed specifically to facilitate exploration of the mechanisms by which clinical supervision enables Health Professionals to deliver a brief, tailored psychosocial intervention in the context of their everyday practice. This is the first study to use discourse analysis embedded within an experimental randomized control trial to explore the mechanisms of change generated within clinical supervision by analysing the discourse within the clinical supervision sessions.

Reflective practice groups for nurses: a consultation liaison psychiatry nursing initiative: part 2--the evaluation

This paper outlines an evaluation of reflective practice groups (RPG) involving nurses and midwives from three clinical nursing specialties at Redcliffe and Caboolture Hospitals, Queensland, Australia. The groups were facilitated by the consultation liaison psychiatry nurse and author using a process-focused, whole-of-group approach to explore clinical narrative in a supportive group setting. This was a preliminary evaluation utilizing a recently-developed tool, the Clinical Supervision Evaluation Questionnaire, along with externally-facilitated focus groups. Nurses and midwives responded favourably to RPG, reporting a positive impact on clinical practice, self-awareness, and resilience. The majority of participants considered RPG had positive implications for team functioning. The focus groups identified the importance of facilitation style and the need to address aspects of workplace culture to enable group development and enhance the capacity for reflection. Evaluation of the data indicates this style of RPG can improve reflective thinking, promote team cohesion, and provide support for nurses and midwives working in clinical settings. Following on from this study, a second phase of research has commenced, providing more detailed, longitudinal evaluation across a larger, more diverse group of nurses.

Mental health nurses' views on therapeutic optimism

Registered nurses (RN) coordinate acute mental health units on a 24-hour basis and it behoves researchers to actually ask these nurses what they think contributes to their ability to work with patients in optimistic ways. In this study, 40 RN working in acute mental health settings were asked a series of questions to explore positive aspects of nursing work, which includes therapeutic optimism. Three themes were identified: (i) different ways nurses foster therapeutic optimism; (ii) perceptions of how an optimistic environment is fostered, and (iii) improvement of ward culture. Findings show the pivotal role mental health nurses have in improving teamwork, good communication, sharing, and collaboration, in addition to preceptoring and supervision. Furthermore, effective clinical management is essential to therapeutic optimism and, in this research, is considered to be the aspect of acute mental health nursing most relevant to improving the ward culture.

Leadership, support and acknowledgement of registered nurses work in acute mental health units

In acute mental health inpatient units, it is not surprising that culture, peers, immediate management, and sources of support and acknowledgment all contribute to positive nursing outcomes. In this qualitative study, four questions targeting leadership, culture, support, and acknowledgement of work well done were asked of 40 registered nurses (RN) working in acute mental health units. Findings convey a mixed picture indicating variation across units. Three-quarters believe that senior nursing staff actively contribute to a positive working environment. Almost half of the RN nominated peers as the providers of counsel and support when required, and a similar percentage believed that senior nursing staff fulfil these roles. Of interviewees, 33% said their nursing achievements are never, or rarely, acknowledged. For these RN, management, peers, and nurse unit managers are the preferred personnel to provide appropriate positive feedback. Thus, there is a gap between the expectations and hopes that nurses have for senior management approaches and behaviours and the reality of their daily experience. Overall, the responses portray a culture that underpins and enables both subtle interpersonal interactions that might arise out of necessity given the perceived lack of support from non-hands-on RN and administrators.

Implementing clinical supervision for ICU Outreach Nurses: a case study of their journey

INTRODUCTION

Many health services with Intensive Care Units have developed ward liaison programs, managed by Outreach Nurses, to facilitate the transition for patients between the intensive care and general wards. This paper reports a case study of clinical supervision for two Outreach Nurses as they adapted to their new, largely autonomous role in an Australian tertiary hospital.

METHOD

Individual clinical supervision was provided fortnightly to two Outreach Nurses over 12 months by an experienced facilitator, and evaluated using a case study methodology. The Outreach Nurses completed a journal that captured their personal and professional growth and the supervisor also provided a reflective account. An interview was conducted with both Outreach Nurses to evaluate their experiences of clinical supervision.

FINDINGS

Key themes emerging from all the data sources included: respect for clinical supervision and the supervisor; role clarification; understanding and dealing with interpersonal issues; dedicated time for reflection; facing up to issues and letting them go.

CONCLUSION

The Outreach Nurses described the personal and professional benefits of clinical supervision and highlighted how it was successfully implemented for them in a busy clinical environment with limited available resources.

Psychiatric nursing staff members' reflections on participating in group-based clinical supervision: a semistructured interview study

This paper is a report of an interview study exploring psychiatric hospital nursing staff members' reflections on participating in supervision. Clinical supervision is a pedagogical process designed to direct, develop, and support clinical nurses. Participation rates in clinical supervision in psychiatric settings have been reported to be relatively low. Qualitative research indicates that staff members appreciate clinical supervision, but paradoxically, do not prioritize participation and find participation emotionally challenging. Little is known about these contradictory experiences and how they influence participation rates. Twenty-two psychiatric hospital nursing staff members were interviewed with a semistructured interview guide. Interview transcripts were interpreted by means of Ricoeur's hermeneutic method. The respondents understood clinical supervision to be beneficial, but with very limited impact on their clinical practice. Neither management nor the staff effectively prioritized clinical supervision, which added to a downward spiral where low levels of participation undermined the potential benefits of clinical supervision. The respondents embraced and used alternative forums for getting emotional support among peers, but maintained that formalized supervision was the only forum for reflection that could solve the most difficult situations.

Ethnographic research into nursing in acute adult mental health units: a review

Acute inpatient mental health units are busy and sometimes chaotic settings, with high bed occupancy rates. These settings include acutely unwell patients, busy staff, and a milieu characterised by unpredictable interactions and events. This paper is a report of a literature review conducted to identify, analyse, and synthesize ethnographic research in adult acute inpatient mental health units. Several electronic databases were searched using relevant keywords to identify studies published from 1990-present. Additional searches were conducted using reference lists. Ethnographic studies published in English were included if they investigated acute inpatient care in adult settings. Papers were excluded if the unit under study was not exclusively for patients in the acute phase of their mental illness, or where the original study was not fully ethnographic. Ten research studies meeting our criteria were found (21 papers). Findings were grouped into the following overarching categories: (1) Micro-skills; (2) Collectivity; (3) Pragmatism; and (4) Reframing of nursing activities. The results of this ethnographic review reveal the complexity, patient-orientation, and productivity of some nursing interventions that may not have been observed or understood without the use of this research method. Additional quality research should focus on redefining clinical priorities and philosophies to ensure everyday care is aligned constructively with the expectations of stakeholders and is consistent with policy and the realities of the organisational setting. We have more to learn from each other with regard to the effective nursing care of inpatients who are acutely disturbed.

Psychiatric hospital nursing staff's experiences of participating in group-based clinical supervision: an interview study

Group-based clinical supervision is commonly offered as a stress-reducing intervention in psychiatric settings, but nurses often feel ambivalent about participating. This study aimed at exploring psychiatric nurses' experiences of participating in group-based supervision and identifying psychosocial reasons for their ambivalence. Semi-structured interviews were conducted with 22 psychiatric nurses at a Danish university hospital. The results indicated that participation in clinical supervision was difficult for the nurses because of an uncomfortable exposure to the professional community. The sense of exposure was caused by the particular interactional organisation during the sessions, which brought to light pre-existing but covert conflicts among the nurses.

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.

Individual and workplace factors that influence psychiatric nursing staff's participation in clinical supervision: a survey study and prospective longitudinal registration

This paper reports findings from a survey of 239 psychiatric nursing staff. This study aimed to investigate how often psychiatric nursing staff participates in clinical supervision and any possible associations among individual and workplace factors in relation to participation. The survey findings are followed by a prospective longitudinal registration of participants in clinical supervision. The registration revealed that participation varies considerably and large numbers of the staff may not participate in clinical supervision at all. Characteristics of the workplace, including organisational location, work shift, and work-environmental factors, are related to participation and, consequently, may affect the outcome of clinical supervision.

Empirical studies of clinical supervision in psychiatric nursing: A systematic literature review and methodological critique

The objective of this paper was to systematically review and critically evaluate all English language research papers reporting empirical studies of clinical supervision in psychiatric nursing. The first part of the search strategy was a combination of brief and building block strategies in the PubMed, CINAHL, and PsycINFO databases. The second part was a citation pearl growing strategy with reviews of 179 reference lists. In total, the search strategy demonstrated a low level of precision and a high level of recall. Thirty four articles met the criteria of the review and were systematically evaluated using three checklists. The findings were summarized by using a new checklist with nine overall questions regarding the studies' design, methods, findings, and limitations. The studies were categorized as: (i) effect studies; (ii) survey studies; (iii) interview studies; and (iv) case studies. In general, the studies were relatively small scale; they used relatively new and basic methods for data collection and analysis, and rarely included sufficient strategies for identifying confounding factors or how the researchers' preconceptions influenced the analyses. Empirical research of clinical supervision in psychiatric nursing was characterized by a basic lack of agreement about which models and instruments to use. Challenges and recommendations for future research are discussed. Clinical supervision in psychiatric nursing was commonly perceived as a good thing, but there was limited empirical evidence supporting this claim.

Refocusing acute psychiatry, performance management, standards and accountability, a new context for mental health nursing

The term 'performance management' has an aversive 'managerial' aspect, is unappealing to many public sector staff and has an 'image problem'. Perhaps as a consequence, it has failed to make a significant impact on Irish public sector workers, notably mental health nurses. In this paper, performance management is introduced and examined within an Irish healthcare context and with reference to its use in other countries. Some of the challenges faced by Irish mental health nurses and the potential benefits of working within a performance managed workplace are discussed. The paper concludes that performance management is likely to increasingly affect nurses, either as active agents or as passive recipients of a change that is thrust on them. The authors anticipate that the performance management 'image problem' will give way to recognition that this is a fundamental change which has the potential to enable health services to change. This change will bring high standards of transparency, worker involvement in decision making, an explicit value base for health services and individual teams. It provides the potential for clear practice standards and high standards of transparency as well as worker welfare in all aspects, including supporting employment and career progression.

Mental health nurses establishing psychosocial interventions within acute inpatient settings

Acute inpatient units provide care for the most acutely unwell people experiencing a mental illness. As a result, the focus for care is on the containment of difficult behaviour and the management of those considered to be 'at high risk' of harm. Subsequently, recovery-based philosophies are being eroded, and psychosocial interventions are not being provided. Despite the pivotal role that mental health nurses play in the treatment process in the acute inpatient setting, a review of the literature indicates that mental health nursing practice is too custodial, and essentially operates within an observational framework without actively providing psychosocial interventions. This paper will discuss the problems with mental health nursing practice in acute inpatient units highlighted in the current literature. It will then put forward the argument for routine use of psychosocial interventions as a means of addressing some of these problems.

Clinical supervision in the alcohol and other drugs field: an imperative or an option?

There is a growing interest in Clinical Supervision (CS) as a central workforce development (WFD) strategy. This paper provides a definition of and rationale for CS, characterises its various forms, identifies selection and training issues, and advises on policy and implementation issues central to redressing shortcomings in supervision practice within the alcohol and other drugs (AOD) field. Relevant selective literature is reviewed. Key conceptual issues were identified, and strategies developed to address implementation barriers and facilitate relevant policy. There is a common conceptual confusion between administrative supervision and CS. Clarification of the role, function and implementation of CS is required. Priority issues for the AOD field include: enhancing belief in CS; ensuring adequate resource allocation; developing evaluation protocols; and addressing specific arrangements under which supervision should occur. CS has been underutilised to date but holds considerable potential as a WFD strategy. It is fundamental to workers' professional development, can contribute to worker satisfaction and retention, and may improve client outcomes. Critical next steps are to establish the generalisability to the AOD field of the benefits observed from CS in other disciplines, and evaluate longer-term gains of CS programs.

Fostering a culture of support in mental health settings: alternatives to traditional models of clinical supervision

Clinical supervision [CS] for mental health nurses in inpatient settings in Sydney, Australia, is virtually nonexistent despite over a decade of discussion regarding its benefits to staff, patients, and organisations. Whilst there is general agreement about the merit of CS, its ad-hoc implementation and the use of models that do not correspond to the realities of the environment have led to its adoption being somewhat half-hearted. It is unsurprising then that there is an absence of achievable policy regarding CS making its integration into modern inpatient units even harder to attain. In this paper, we outline some pragmatic issues concerning CS and advocate for facility-specific professional development and support processes that incorporate succession planning opportunities. This we believe has the potential to promote professional behaviour, continuous learning and development, cohesive teamwork, and ultimately a change in culture regarding CS.