Clinical supervision of general nurses in a busy medical ward of a teaching hospital

Wendy Cross
Head, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University VIC

Alan Moore
Southern Health, Clayton VIC

Sherene Ockerby
Southern Health, Clayton VIC

PP: 245 - 253

Abstract

Aim: To implement and evaluate group clinical supervision (CS) for Associate Nurse Unit Managers (ANUMs) in a busy medical ward of a tertiary teaching hospital.

Background: Nursing work at managerial level is characterised by high stress, depersonalisation and burnout often leading to job dissatisfaction. CS was introduced as a strategy to reduce such issues, through reflection and sharing experiences.

Method: Six ANUMs from an acute medical ward participated in weekly CS. The program was evaluated by a focus group conducted after six months to gather feedback about the ANUMs' experience of participating in CS.

Results: CS was viewed positively and five main themes emerged including Dedicated Time, I'm Not The Only One experiencing problems, Getting With The Program and having consistent approaches, Positive And Constructive Feedback, and That Word 'supervision'. 

Conclusions: CS provides senior nurses an opportunity to debrief, reflect and share common experiences and develop alternate approaches to problems. CS may offer managers a useful tool for retaining experienced senior nurses.

Keywords

Nursing; clinical supervision; management; reflective practice; burnout; stress

Article Text

This paper reports on a pilot study of 'peer group' Clinical Supervision (CS) for Associate Nurse Unit Managers (ANUMs) working on a high dependency respiratory medicine ward in a tertiary teaching hospital. The paper will describe the process of implementation and the focus group evaluation of the CS.

Literature review

Clinical supervision in nursing has been described by Cutcliffe (2005: 417) as a 'global phenomenon', however, it is a notion that lacks clear definition both in terms of its conceptualisation and operationalisation (Lyth 2000; Mills, Francis & Bonner 2005; Williams, French & Higgs 2005; Winstanley & White 2003).

Despite the inconsistency in conceptualisation, Winstanley & White (2003) acknowledge that there are common threads that run through most definitions, in that it involves the provision of empathetic support to improve clinical skills and knowledge and foster a culture of reflective practice. Furthermore, this process takes place within a supportive environment in which the individuals are able to develop their own clinical practice and lend support to others.

The concept of CS in nursing dates back to the early 1900s with a conference on this topic held in New York in 1925 (Yegdich 1999). While CS has traditionally been used in the areas of social work, psychiatry and psychology (Cleary & Freeman 2005), its popularity in UK nursing became evident in the late 1980s (Mills et al 2005; Winstanley & White 2003). Despite its widespread use internationally, Australia has been slow to recognise the value of CS in hospital nursing, although it has gained popularity in community nursing and, in particular, mental heath nursing (Winstanley & White 2003).

The raison d'être of any hospital is to provide continuous care to sick persons 24 hours a day, 365 days per year. As early as 1970, Menzies acknowledged that primary responsibility for performing this role lies with nursing staff. Nursing is a particularly challenging occupation because staff are expected to cope with the immediate and concentrated impact of stress relating to direct patient care every time they enter the clinical setting (Lyth 2000).

As the nursing profession is expected to take on greater responsibility and practice under increasingly stressful conditions, Lyth (2000) highlights that support such as that provided by CS can only be a positive in the professional and personal development of the workforce. Clegg (2001) suggests that CS has been embraced by the nursing profession as a strategy to address occupational stress. Specifically, the process of supporting staff through stressful work experiences within the context of CS helps staff to make sense of their stressful environment and allow them to manage it more effectively.

In a study of 512 Finnish psychiatric and mental health nurses who had participated in CS, Hyrkäs (2005) found that a positive evaluation of CS using the Manchester Clinical Supervision Scale (MCSS) was related to lower levels of depersonalisation and personal accomplishment measures on the Maslach Burnout Inventory (MBI), and a less positive evaluation of CS was associated with increasing job dissatisfaction.

Edwards et al (2006) found that high evaluations on the MCCS were associated with lower levels of burnout amongst 260 Welsh community nurses. Specifically, there was a negative correlation between the total MCSS score and the emotional exhaustion and depersonalisation scales of the MBI. 

In another Finnish study, Hyrkäs, Appelqvist-Schmidlechner and Haataja (2006) investigated the efficacy of CS with regards to job satisfaction, burnout and quality of patient care. Over 700 staff were surveyed including general registered nurses, mental health nurses, and specialist nurses, using validated tools such as the MCSS and MBI. As with other research, evaluation of CS was found to predict burnout and job satisfaction as well as their perception of good nursing. Furthermore, results indicated that there were significant differences in nurses' evaluation of CS relating to the characteristics of both the respondents and the supervisor. Winstanley & White (2003) emphasise that flexibility is required for the implementation of successful CS rather than a 'one size fits all' approach and this Finnish research supports this notion.

Several authors describe the various models of CS which range from one-on-one supervision to multidisciplinary group supervision (McSherry, Kell & Pearce 2002; Winstanley & White 2003). One advantage of group supervision is that it is more cost-effective and efficient than one-on-one supervision in terms of reducing the time nurses spend away from the busy clinical environment and direct patient care (Jones 2003; Winstanley & White 2003).

One of the key barriers to implementing CS on a hospital ward is time (Cleary & Freeman 2005; Cole 2002; Stevenson 2005; Williams et al 2005). Various issues relating to the unpredictable nature of patient care and with rotating staff rosters mean that CS is not viewed as a priority. However Cole (2002) argues that the very fact that nurses are rushed off their feet makes CS all the more important because it provides them with a time-out to reflect on what they are doing.

The concept of CS is still quite novel for hospital-based nurses in Australia and there is often scepticism and mistrust about its purpose. Several authors suggest that there is a degree of resistance and mistrust of CS among nurses (Cole 2002; Stevenson 2005; Winstanley & White 2003; Yegdich 1999). Given the range of definitions of CS in the literature, it is likely that nurses are unclear about its purpose and perceive supervision in a negative light and related to performance management.

While there are various methods of group supervision, peer group supervision involves a group of nurses who are at the same level of clinical practice. It is thought that peer group supervision can be less threatening than other group methods (McSherry et al 2002) and, given that all group members are from a similar practice level, this provides an opportunity for discussion of issues that are pertinent to their work role. Winstanley & White (2003) suggest that respondents who participate in group sessions rate the advice and support provided by the supervisor as more effective than those who receive one-on-one supervision.

Whilst CS is becoming more popular for general nurses in hospital settings, there is little research surrounding the role of supervision for more senior nurses who perform a management role within hospital wards. Their daily responsibilities are quite removed from those of the general nursing population and consequently their CS needs and the desired outcomes are also quite different.

In the Australian context, a cohort of Associate Nurse Unit Managers (ANUMs) typically share responsibility for managing the ward in the absence of the Nurse Unit Manager (NUM) who is in charge of the ward. They have approximately one shift per month allocated for management purposes which allows for such activities as the development of policies and procedures and rostering. This paper reports on a pilot study of 'peer group' CS for ANUMs on a high dependency respiratory medicine ward in a tertiary hospital. This includes a description of the process involved in implementing the CS program and presentation of findings from a focus group conducted with the ANUMS to evaluate the program.

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