Most Relevant Clinical Supervision Strategies In Nursing Practice

Abstract

Clinical supervision (CS) is a facilitator of professional development and quality of practice, promoting safety and protection of clients, through the adoption of targeted strategies.Portugal has been developing research aiming to design policies that support the implementation of CS based on partnerships between academic and practice nurses. This strategy empowers professionals with skills essential for professional development. The study aims to identify the most relevant CS strategies according to nurses’ perspective. A quantitative and exploratory study was developed. Data were collected from questionnaires between May and October 2012. The convenience sample included 273 nurses working in hospitals (64.3%) and health care centers (35.7%) in Portugal, 83.2% were females, aged between 24-58 years. Nursing professional experience ranged between 1-36 years. The majority of the participants (87.5%) considered CS important to professional development. CS strategies relevance: reflective practice (45.8%); feedback (45.8%); observation (45.1%); continuing education (44,3%); support (41.8%); demonstration (40.7%); individual sessions (37.4%); self-supervision (37.0%); cases analysis with supervision (31.9%); analysis of nursing documentation (30.8%); group cases analysis (22.7%); group sessions (21.6%), reflexive report (16.5%); distance supervision: e-mail (7.7%), phone (7.7%) and skype® (4.0%). The participation of nurses in the design of CS policies is considered meaningful and highly relevant to nursing practice, empowering nurses with qualified skills and contributing to improve the quality of interventions. This research is a valuable input to the development and innovation in nursing, contributing to the design of CS policies based on strategies that nurses consider more appropriate and relevant to practice and professional development.

Keywords: Nursing, clinical supervision, strategies

Introduction

This study was developed as part of the research "Conception of a Nursing Clinical Supervision Program in Primary Health Care", conducted during the PhD in Nursing Sciences at Universidade Católica Portuguesa (Catholic University), with the aim of gathering quantitative data on the relevance given by nurses to CS strategies.

Since the existing scientific evidence shows no instrument providing this specific information, researchers decided to design the "Questionnaire for assessing the relevance of nursing clinical supervision strategies - QARESCE". This questionnaire enabled to collect data essential for the purposes and the research questions of this study, aiming to contribute to the improvement of quality of care, by identifying the most relevant nursing CS strategies. Simultaneously, it was intended to promote the involvement and participation of nurses in the design and implementation of a meaningful CS programme targeted at mastering nursing and professional practice.

Problem statement

CS is a formal professional process that facilitates the development of knowledge, skills, and accountability, promoting the quality of care and the safety of clients . A solid conceptual framework should underlie this model, based on teaching, pedagogical and formative principles implying the adoption of specific strategies.

The clinical supervisor is crucial to the development of the supervisee, either in their technical and scientific training or in ethics, which will likely determine the professional performance. Thus, the supervisor should focus on a reflective training, in order to challenge, stimulate and help the supervisee in developing and mastering abilities and skills leading to a solid professional commitment .

The reflective training approach should be based on the Schön (1987) perspective: by context interaction, through the observation and reflection on these specific situations; in identifying problems; in proposing solutions, and should be tailored to each participant, considering that "different people learn and develop differently”. In the process of training and professional individual development, it is important that the supervisor considers interventions helping to focus on personal meanings, which comprises the following phases: the supervisor is faced with situations, collects and analyses information/data; reflects on what to do to support training; plans and implements sustainable strategies (Sá-Chaves, 2000).

Based on the study developed by Sá-Chaves (2000) this study researchers perceive supervision as a non-standard procedure which should be continuously reflected, considering that: the human being is a unique and indivisible entity; strategies should be tailored to each single individual; the personal human nature should be highlighted rather than the model itself. Thus, the supervision models should be used in a critical-reflective way and considered only as guidelines, since often models and supervision strategies need to be adapted.

Aiming to ensure the effectiveness of the nursing CS implementation and enhancement of nurses personal and professional development, the clinical supervisor must have supervision skills, training, teaching and pedagogical knowledge and should consider the adoption of specific strategies and methodologies, ensuring all the appropriate resources pertaining to training and development needs (Alarcão & Tavares, 2010; Moura & Mesquita, 2010; Sá-Chaves, 2000). This means that the adopted supervision strategies are key elements to personal and professional development of the supervisee, to the enhancement of well-being and for mastering professional practice.

Research questions

Which are the clinical supervision strategies that nurses consider the most relevant?

Purpose of the study

To identify the clinical supervision strategies that nurses consider the most relevant.

Research Methods

To address this question, a quantitative paradigm was adopted and an exploratory and descriptive study was performed.

Relevant data were collected through the "Questionnaire for assessing the relevance of nursing clinical supervision strategies - QARESCE".

The first part of the questionnaire included 20 questions addressing the socio-demographic and professional characterization of the participants. The second part consisted of 16 statements regarding the supervision strategies most frequently adopted, according to the analysed evidence. Each question had a set of five possible answers, based on a 5-point Likert scale, where 1 was "Not Relevant", 2 "Little Relevant", 3 "Relevant", 4 "Very Relevant" and 5 "Totally Relevant".

The ranking of the most relevant strategies was determined through the highest % on score 5, plus score 4 (if two or more strategies were scored 5).

The questionnaire was submitted to six national and four international experts, teachers with research expertise in the area of the nursing CS and education sciences, during the month of February 2012, and submitted to a pre-test in April 2012. The sample comprised 10 nurses without specific nursing CS training and nine with this specific training.

Data collection was performed between May and September 2012, in two hospitals and primary health care centers in the north of Portugal through paper questionnaires handed in the healthcare units. In addition, online questionnaires were emailed to nurses working in different contexts and institutions of several regions of Portugal (mainland and islands).

Findings

This study findings reveal that the "critical and reflective practice analysis" strategy is considered the most relevant (table 1); 45.8% of the participants considered this strategy Totally Relevant (TR) and 39.6% Very Relevant (VR). These results show the importance of reflection to CS, which is based on intrapersonal and interpersonal reflective processes (Kim, 2010). The critical-reflective analysis is crucial to the profession, leading to the restructuring of interpretations and practices, to the extent that through this analysis higher levels of understanding on professional issues are attained, and solutions are more likely to be found for the different types of challenges faced by nurses, promoting self-autonomy and enhancing quality of professional practices (Hirkäs, Lehti & Paunonen-Ilmonen, 2001; Schön, 1987).

It is essential that health institutions provide the nursing professionals time for the systematic incorporation of reflection "for action", "in action", "on the action" and "about the reflection on action". This is an important aspect, since quality demands reflection on practices in order to enable the identification of problems, to set goals and related strategies, and this requires time for decision-making based on evidence (Henderson, 2014; Schön, 1987; Te Pou, 2009; Winstanley & White, 2003). Nurses consider of major relevance the reflective practice analysis, since this is the basis for all other strategies and crucial to nurses’ professional practice and for the supervision processes. Thus, it is imperative that the supervisor includes this model in all supervision practices.

Feedback, is the second most relevant strategy, 45.8% considered it Totally Relevant and 37.7% very Relevant. This strategy provides the supervisee an insight on self-performance: strengths, areas that need improvement and individual potential, in order to promote awareness on personal and professional development (Clynes & Raftery, 2008; Ping, 2008).

To give and have feedback on practice is a fundamental goal for nursing clinical supervision (Kieseker, 2013). Like reflection, the positive or negative feedback must be a part of nursing and supervision practices in self and hetero-reflective processes, in order to encourage a reflective practice (Clynes & Raftery, 2008; Myall, Levett-Jones & Lathlean, 2008). According to Rocha (2013) when referring to the less recommended strategies, feedback was rarely mentioned by nurses.

Observation is an organized process of gathering information on the supervisee, and is used as a starting point of the reflection on action (Alarcão & Tavares, 2010), and in this study 45.1% of the participants considered it Totally Relevant. Direct observation must be the supervisor work-based approach, since it is one of the most effective ways to monitor the development of skills, performance and the supervisee competencies (Center for Substance Abuse Treatment, 2009), which explains why nurses consider this highly relevant. Rocha (2013) concluded that the observation was the CS strategy most often implemented and preferred in health services.

Continuing education is based on the training framework of CS and should be outlined in an integrative way in the supervision process, since this is considered of major relevance to nurses’ professional practice. It also contributes to the enhancement of skills, to encourage self-training, research, innovation, acquisition of skills, competencies and knowledge, favouring the development of self-autonomy and fostering the processes of change (Decree-Law no. 207/96 dated 2 November, pp 3879-3880; Guerra, 2008; Pires, 2004). Continuing education was found to be the fourth most relevant strategy (44.3% TR).

The relevance of this strategy in supervision is recognized due to its impact on personal and professional development of individuals and institutions, pertaining to development, innovation and the evolution of contexts, all these factors contributing to the quality of professional practice (Sousa, 2003).

The fifth most relevant strategy found was support (41.8% TR). Support is a strategy underlying the restorative function of CS, and evidence suggests that CS guarantees support to professionals through the supervisor feedback, providing assistance and relief from stress. The restorative function of CS has been a frequent approach in research, considering that this is a stressful profession demanding for effective support (Brunero & Stein-Parbury, 2008).

The relevance attributed to this strategy by the study participants is in line with the importance associated with support, aiming to help professionals manage their own emotions and feelings. This will likely help them not to feel isolated, and also provide feelings of security and self-confidence, but also instrumental and scientific support to their professional practices (Brunero & Stein-Parbury, 2008; Pires, 2004; Vieira, 2014).

The quality of support and established relationships are very important factors in the development of clinical expertise and in building the professional identity of the supervisee (Laitinen-Väänänen, Talvitie & Luukka, 2007). This corroborates the study findings of Rocha (2013), showing that this was considered the third most frequently implemented and preferred strategy.

The Demonstration strategy refers to the exemplification methods used by the supervisor to teach or explain the supervisee how to approach a situation or procedure that needs to be learned or enhanced (Rothgeb, 2008), and in this study this was found to be the sixth most relevant strategy (40.7% TR). The study developed by Rocha (2013) shows that this was the second most frequent implemented and preferred strategy in healthcare centers.

Individual supervision sessions are rated in the seventh position (37.4% TR) and group supervision sessions in the twelfth position (21.6% TR). Individual sessions (1:1 or one-to-one) consist of a formal and structured strategy which increases interaction between supervisor and supervisee. This strategy aims to reflect on the supervisee practices in a constructive way. The group sessions are conducted with groups (four to six supervisee participants), led by the supervisor (Bégat, Berggren, Ellefsen & Severinsson, 2003; Potter, 2004; Winstanley & White, 2003).

Barribal, While & Münch (2004) refer that no consensus has been reached on the type of sessions providing better results. Potter (2004) considers that when adopting these interventions the wishes and needs of professionals should be addressed, along with the institutions’ goals. The fact that participants consider the individual sessions as more relevant, corroborates the study findings showing that 1:1 sessions are more likely to be adopted and are the most preferred by supervisor and supervisee. These sessions are considered being more effective and likely to reduce anxiety triggered during group sessions. This is an aspect also evidenced in the studies performed by Barriball, While & Münch (2004) stressing that some supervisee participants may feel more comfortable with the supervision model 1:1, when a good interpersonal relationship with the supervisor has already been established (Edwards et al., 2005; Fowler, Fenton & Riley, 2007; Tavares, 2013; Winstanley & White, 2003;). However, several studies also show that the group sessions can provide a valuable learning and experiences exchange (Edwards et al., 2005; South Gloucestershire, 2011).

Findings in the study performed by Rocha (2013) evidence that the majority of nurses wish to engage in individual sessions rather than in group sessions.

Self-supervision was considered Totally Relevant by 37.0% of the participants. This is an introspection metacognitive strategy, of self-analysis and self-reflection which helps to build the person’s identity while involving the individual in an intrapersonal questioning of self-practices. This will lead to an understanding of the factors likely to influence change (Larrosa, 2000). The metacognitive ability is an important factor contributing for the awareness of the processes underlying the professional practice and to the implementation of self-guided changes. Thus, nurses should be able to demonstrate critical reasoning on their practices and related scientific evidence (Grilo & Grilo, 2011). The nurses’ practice should comprise interventions that are continuously under self-analysis and self-assessment, aiming to redefine, reformulate and change procedures.

Analysis of cases with the supervisee is the ninth strategy considered most relevant by nurses (31.9% TR), and analysis of cases in group is the eleventh (22.7% TR). The first involves the interaction between the supervisor and supervisee, within a contextualized analysis of significant real or hypothetical episodes or specific cases. The purpose is to foster reasoning and in-depth reflection on a given situation, and the supervisee should be empowered with skills to design interventions, through discussion and reflective learning (Alarcão & Tavares, 2010; Garrido, Simões & Pires, 2008). The analysis of cases in groups differs from the first approach because it involves interaction between the supervisor and a group of supervisee, promoting experiences exchange.

The reflection, discussion and sharing of experiences with the team, helps in the development of skills, hence these strategies have a strong impact in the effectiveness of nursing CS (Paton & Binding, 2009).

The analysis of the nursing care documentation is a strategy that allows the supervisor to access essential data, contributing to the reflection process with the supervisee on the conception, implementation and assessment of care. This will enable the supervisor to assess the supervisee professional abilities pertaining to the conception of care (Abdon et al., 2009; Carvalho, 2012).

Reflective report was one of the strategies considered less relevant by the participants. Only 16.5% consider it as Totally Relevant (thirteenth position). This strategy provides the supervisee with an essential tool to express thoughts, knowledge and emotions, highlighting the most relevant self-perceived aspects of practice. Since writing is a reflective action, this strategy is an important action-reflection instrument mainly intended to promote the reflection mechanisms, self-analysis, self-awareness and self-assessment of the supervisee (Hong & Chew, 2008; Silva & Sá-Chaves, 2008).

In the study of Rocha (2013) the reflective report is rated in the last position concerning the strategies that nurses would like to see implemented in health services. This evidence might be explained by the fact that a reflective report can often be a difficult and stressful task, since in addition to the review process, the written reflection might be viewed by the supervisee as an assessment instrument itself (Bishop, 2006).

Distance supervision using ICT enables real time or scheduled communication between supervisor and supervisee, allowing these latter to share information, reflect on the practices or be provided with support (Prado & Rosa, 2008; Todd & O'Connor, 2005).

In this study these strategies were found to be rated in the last positions (Distance supervision: e-mail, in the fourteenth position 7.7% Totally Relevant and 18.3% Very Relevant; by phone, in the fifteenth position 7.7% Totally Relevant and 16.5% Very Relevant; by Skype®, in the sixteenth position 4.0% Totally Relevant). These findings are likely to be related to the fact that Portugal is a relatively small country when compared to other larger countries, in which distances are more easily and effectively bridged using these strategies, enabling professionals of rural or remote areas to have access to CS. Thus, the fact that these professionals can be provided with distance supervision will facilitate communication, knowledge and experiences sharing (Thompson & Winter, 2004; Todd & O’Connor, 2005; Wagner, Keane, McLeod & Bishop, 2008).

Some studies have suggested that the e-mail is the ICT more likely to be used by nurses, which is also observed in the study of Rocha (2013), showing that this technological resource is the most appreciated by respondents, when even compared with the telephone. In the study developed by Graf & Stebnicji (2002) the supervisee reveal that supervision using this communication tool provides them with more support and resources, considering it an important aid in addition to face-to-face strategies and a feasible way to ask and get information.

Distance supervision using the telephone was used by Thompson & Winter (2004) in a very successful project aiming to implement CS in a primary care trust. Robson & Whelan (2006) concluded that the use of the telephone is more significant for the supervisee working in more isolated areas or locations distant from the main working place.

Marrow et al., (2002) found that the distance supervision strategies are not often adopted in hospital settings but widely implemented in primary health care units and that nurses working in rural areas prefer the ICT enabling visual communication.

Conclusions

CS is a facilitator process of professional development, contributing to the quality of practice, promoting safety of care and protection of clients in clinical complex situations. In the supervisory processes it is critical that clinical supervisors mobilize appropriate CS strategies in order to facilitate the development of the supervisee.

It is a relevant indicator that the participants have considered the "critical and reflective practice analysis" as the most important strategy, followed by the "Feedback" and "Observation", since it is in the intrapersonal and interpersonal reflective processes "for action", “in action", "on the action" and "about the reflection on action", that the basis for CS is grounded. These critical-reflexive strategies are key elements to the supervision practices if supervisors are able to mobilize these same strategies, based on the observation and monitoring of the development and performance of the supervisee, and considering this the starting point of the reflection on action.

It is important to stress out that having participants attributed a major relevance to analytical and critical-reflexive oriented strategies, similar to what happened in the individual and group supervision sessions, a greater importance was given to the analysis of cases with supervisee than to the analysis of cases in group. This means that the focus was on the individual rather than on the group strategies. It is considered that this should be an important issue to address in future research, since nursing is primarily an interactive profession, involving a strong relational component, teamwork and multidisciplinary discussion on practices. Thus, nurses seem to prefer strategies that involve intrapersonal analysis and reflection rather than the ones involving interpersonal approaches.

Despite the importance of ICT as an essential mechanism for facilitating the CS, especially in countries where great distances often create barriers in accessing information, in this study the distance supervision strategies were considered the less relevant. This indicator might lead to different interpretations, hence the need for further research. In fact, Portugal does not have major geographical barriers, when compared to other countries, and this is mainly due to its extended and improved road network. Nevertheless, these strategies could be enhanced since Portugal is at the forefront of the new IC technologies.

It would also be important to understand why, contrary to evidence-based findings, participants prefer ICT that do not involve visual contact, as the e-mail and telephone, rather than Skype communications that allows this type of communication. Once again, this result emphasizes the need to address the interaction issues in future research.

In sum, the identification of this set of strategies are seen as an important contribution to the design of a nursing CS program based on strategies that nurses consider more relevant to their professional development.

Acknowledgements

We would like to thank Dra. Maria do Amparo Alves for the collaboration in the translation of this paper.

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