CLINICAL SUPERVISION IN PRACTICE AND DISTRICT NURSING: A LITERATURE REVIEW
The following research reports a systematic literature review of studies which have assessed the development, implementation and outcomes of clinical supervision within practice and district nursing.
Background – The demands which are being placed on nurses within the modern health care environment continue to increase. It is important that effective measures are identified which provide appropriate education, support and quality control for nurses to ensure that they can meet these demands. One such approach is referred to as clinical supervision. Through this, a nurse can be supervised by a more superior colleague who can oversee their actions and make interventions when necessary.
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Aims – This literature review will critically review research which has assessed the development, implementation and outcomes of clinical supervision in practice and district nursing. This will enable an assessment of the effectiveness and efficacy of clinical supervision within this group of health care workers.
Methodology – A systematic literature review was conducted. Relevant articles were identified via computer based searches, manual searches and internet-based searches.
Results – It was found that clinical supervision was developed based on a set of standards but that more work is required to improve the dissemination of these standards, role definitions and to standardise the process of supervisor selection and training. A need was also identified for supervisors to me made more available for both nurses and the supervisors themselves. Finally, the perceived benefits of clinical supervision in terms of support, socialisation into ward culture, providing clinical experience and improving the nurses’ job satisfaction were discussed. Further research is recommended to developed standardised and validated assessment tools to enable empirical analyses of the effect of clinical supervision on nurse performance and the quality of care provided to patients.
Conclusions – Clinical supervision is seen to be an effective way of providing support for practice and district nurses. However, more work is needed to ensure that it is more feasible and that it is not viewed as a form of control or assessment by the nurses.
Keywords – Clinical Supervision Practice District Nursing Evaluation
What do we already know about the topic?
- Clinical Supervision focuses on providing nurses with education, support and management (quality control)
- Health care workers perceive that clinical supervision aids support, skill development, team building, provides a monitor and helps colleagues to share information
- Little research has critically analysed the effectiveness and efficacy of clinical supervision for practice and district nursing
What does this study add to the knowledge in this topic?
- Clinical supervision standards have been developed but they need to be more effectively disseminated, standardised and the roles need to be better defined
- This review highlights the need for there to be an increase in the availability of supervisors for both nurses and the supervisors themselves
- Standardised assessment tools need to be developed and validated to enable an assessment of the effect of clinical supervision on nurse performance and quality of care
The world of nursing has gone through a period of significant change over the last ten years. In the acute nursing environment, nurses are using increasingly more complex health care interventions and have to incorporate the use of advances in both medical technology and disease management. Within primary care, nurses are required to face the burden of chronic disease and to facilitate patients beginning to self manage their own health. Such changes have been made as a result of Governmental policy and strategic approaches (Wanless 2002, Wanless 2004).
Such changes have resulted in there being a range of extra demands being placed upon the nurse, both during and after their training. The Royal College of Nursing (2004a and 2004b) acknowledged the change which is occurring and stated that nurses’ continuous education needs to be assessed and adapted to meet the changing role of the nurse. Changing have particularly taken place within the education of student nurses through the implementation of Project 2000 (UK Central Council for Nursing, Midwifery and Health Visiting 1986)Nurses are now required to undertake tasks which were traditionally performed by doctors. Through these changes the need for effective CLINICAL supervision within nursing has become ever more salient. As a result of the potential effects which a supervisor nurse relationship can have on the nurse’s learning, their experience of training, their subsequent performance on the training course, their future effectiveness as a nurse and ultimately on the quality of the care which is provided by the nurses, it is an important topic to consider within the fields OF BOTH PRACTICE AND DISTRICT nursing.
Much has been written about the practitioner as facilitator, supervisor, assessor and role model, and the overlay of role functions (Windsor 1987, Hughes 1990, Donovan 1990, Bailey 1992). Despite this, there is still a lack of consensus within the literature in terms of a clear definition of what is meant by the term ‘supervisor’ (Hagerty 1986, Phillips et al 1996a, Phillips et al 1996b). It has been argued that the task of defining the term supervisor is made more complicated by the fact that other terms are used, such as assessor, facilitator and mentor, to describe the same role (Phillips et al 1996a, Phillips et al 1996b). As a result of the wide range of aspects of the role which is played by a supervisor, it can be stated that a definition of supervisor can only be a general description as anything more specific would run the risk of excluding important elements of the position (Davies et al 1994). For the purposes of the following review, the definition of supervision which was provided by Zwolski (1982) will be adopted:
‘Supervision is a relationship which is aimed at guiding the novice towards an established place within the profession’ (Zwolski 1982)
In the nursing profession the aims of the supervisor will be to form a relationship with their nurses which enables them to be successful during their training and throughout their subsequent career. Jarvis (1995) emphasised that it is important to focus on the supervisor’s role as a function and as a relationship with the nurse rather than being about them as a teacher or practitioner. Through this role the supervisor can help to narrow the gap between theory and practice (Pelosi-Beaulieu 1988, Armitage and Burnard 1991). Butterworth and Faugier (1994) theorise that the role of clinical supervisor has three key elements, namely Education, Support and Management (through quality control).
However one conceptualises clinical supervision within practice and district nursing, the benefits of the process have been demonstrated through previous research. It has been found that nurses require their supervisor to provide a good role model and to provide a source of support, particularly in the earlier years of a nurse’s career (Gray and Smith 2000). Research has indicated that nurses tend to leave the profession because they cannot cope with the demands of training or the job itself (Fulbrook et al 2000) or because of more personal factors (MORI 2003). It may be that clinical supervision has a broader role to play here in reducing the probability that a nurse will leave the profession. Based on questionnaire research, Thomas and Reid (1995) identified five important benefits of clinical supervision. They were support, skill development, team building, monitoring clinical performance and the sharing of information. The following review will consider research which has focussed on the clinical supervision within practice and district nursing.
A systematic review aims to integrate existing information from a comprehensive range of sources, utilising a scientific replicable approach, which gives a balanced view, hence minimising bias (Hart 1998). In other words, a scientific approach will help to ensure that research evidence is either included or excluded based upon well defined and standardised criteria. This should ensure that the possible effects of researcher bias should be kept to a minimum. Brealey and Glenny (1999) also states that systematic reviews provide a means of integrating valid information from the research literature to provide a basis for rational decision making concerning the provision of healthcare.
4.1 SOURCES OF DATA
The methodology employed within the research will involve obtaining data from three key sources: Computerised searches, Manual searches, and the Internet. Each of these data sources will now be considered in more detail.
4.1.1 COMPUTERISED SEARCHES
Multiple databases, both online and CD–Rom will be accessed to retrieve literature because they cite the majority of relevant texts. (Loy 2000) The computerised bibliographic databases are:-
- British Nursing Info BNI
- Science Direct(All Sciences Electronic Journals)
However because articles may not be correctly indexed within the computerised databases, other strategies will be applied in order to achieve a comprehensive search (Sindhu & Dickson 1997).
4.1.2 MANUAL SEARCHES
A manual search will be performed to ensure that all relevant literature is accessed. The manual searches will include:-
- Books relevant to the topic from university libraries and web sites
- Inverse searching- by locating index terms of relevant journal articles and texts
- Systematically searching reference lists and bibliographies of relevant journal articles and texts
4.1.3 THE INTERNET
The internet will provide a global perspective of the research topic and a searchable database of Internet files collected by a computer.
Sites accessed will include:-
- Department of Health
- National Institute of Clinical Excellence
- English National Board of Nursing, Midwifery and Health Visiting
4.2 IDENTIFICATION OF KEY WORDS
The selection of search terms is an important task. The search needs to be sensitive in that it should identify as many of the key articles as possible. It should also be specific in reducing the number of irrelevant articles which it produces. The search words were derived based on the research question, as recommended by Loy (2000). They were:
- Clinical Supervision
- Practice Nursing
- District Nursing
4.3 INCLUSION AND EXCLUSION CRITERIA.
In order that a manageable quantity of pertinent literature is included in this study, it is essential that inclusion and exclusion criteria are applied. These are outlined below:
4.3.1 INCLUSION CRITERIA
The articles which are highlighted within the proposed searches will be assessed in terms of whether or not they meet the following criteria. Each article will need to be viewed as appropriate with regards to all of these constraints if they are to be included in the final analysis. From the pool of data which is obtained, the most appropriate articles which meet these inclusion criteria will be selected for use within the review.
- A literature review encompassing all methodologies will be applied (International studies will be included
- Available in English
- Relate to Clinical Supervision
- Relate to Practice or District Nursing
4.3.2 EXCLUSION CRITERIA
The articles highlighted by the searches will also be assessed in terms of whether or not they fulfil the following exclusion criteria. If a potentially relevant article meets one or more of these criteria then they will be immediately excluded from the data set and will not be included within the analysis stage of the methodology.
- Articles relating to supervision in industries other than health care will not be included
- Literature in a foreign language will be excluded because of the cost and difficulties in obtaining translation.
- Research reported prior to 1985 will not be included within this review.
4.4 CONSIDERATION OF ETHICAL ISSUES
Any research involving NHS patients/service users, carers, NHS data, organs or tissues, NHS staff, or premises requires the approval of a NHS research ethics committee (Department of Health 2001). A literature review involves commenting on the work of others, work that is primarily published or in the public domain. This research methodology does not require access to confidential case records, staff, patients or clients so permission from an ethics committee is not required to carry out the review. The researcher will also act professionally when identifying, reviewing and reporting relevant studies.
The most relevant research which was identified by the methodology employed within this research will now be critically analysed. In order to structure the discussion more effectively, the analysis will address the three stages which should comprise the evaluation of a training intervention (Kirkpatrick 1979). Thus the discussion will consider the development, implementation and outcomes of clinical supervision in practice and district nursing.
5.1 EVALUATION OF THE DEVELOPMENT OF SUPERVISION PROGRAMMES
Whenever one is considering a health care intervention, it is important to first address the foundations upon which it was developed. In the case of clinical supervision, one must consider the relevant policies and theoretical frameworks. A set of standards which govern the preparation and role of supervisors were produced by the UK Central Council for Nursing, Midwifery and Health Visiting (2004). The English National Board have outlined the five key aspects of the supervisors role: Assisting, Befriending, Guiding, Advising and Counselling (Anforth 1992). Research has been conducted with the aim of evaluating the supervision process from a theoretical perspective as well as those of the nurses and supervisors themselves. This research will now be outlined.
Researchers have conducted reviews of clinical supervision of nurses and have highlighted some potential limitations. Andrews and Wallis (1999) reported that a range of different frameworks for conceptualising the supervisor role were prevalent and that more specific guidelines needed to be developed. They also found that supervisors often attended short and local courses whose effectiveness had not been evaluated. Furthermore, Wilson-Barnett et al (1995) stated that the continued use of terms such as mentor, assessor and facilitator, as well as supervisor, led to confusion of the specific nature of the role. Therefore, it appears that although standards have been developed regarding clinical supervision in nursing, further work may be required to ensure that they are more effectively disseminated.
The process of clinical supervision needs to also be evaluated from the nurses’ perspective. Watson (1999) conducted semi-structured interviews with 35 nurses to investigate their perceptions of the clinical supervision which they had received. Two key findings were reported. Firstly, the respondents reported that they felt that the supervision process was not sufficiently defined by the English National Board. They also felt that the supervision process was not adequately clarified by their internal organisation. Standards were seen to be appropriate but they were not effectively applied to the practical situation. This research did employ a small sample and the extent to which the findings can be generalised to the UK as a whole may be questioned Having said this, these findings do demonstrate that nurses clinical supervision is based on appropriate standards but that the roles of supervision and the person being supervised need to be more specifically defined.
The third and final area of evaluation concerns the supervisors themselves. Cahill (1996) reviewed the relevant research in this area and reported that there are a range of different supervisor selection and training procedures. This ensures that there is sufficient scope for different supervisors to be selected based on different criteria and for them to then go on and receive different levels of training. This lack of standardisation has the potential to mean that the quality of supervision provided throughout the UK may significantly differ. Further research in this field has been reported.
For instance, Neary (1997 and 2000) interviewed 155 clinical supervisors. It was found that there was some confusion over the nature which the supervisor/nurse relationship should take. The supervisors were not clear on what their specific role was and the extent to which they should help their nurses. This causes problems in terms of competency assessment as the supervisors were not clear on what was expected of them and the nurses whom they were supervising. Therefore, issues regarding standardisation and role definition are prevalent within supervisor perceptions of this topic. This section has demonstrated that work is required to improve the dissemination of standards, role definitions and the standardisation of supervisor selection and training.
5.2 EVALUATION OF THE IMPLEMENTATION OF SUPERVISION PROGRAMMES
A relevant research study which has been conducted in this area involved nurses and their supervisors completing activity diaries for a week (Lloyd-Jones et al 2001). The data provided via the activity diaries were then analysed in order to determine the extent to which the nurses were adequately supervised and what happened when their supervisors were not present. It was reported within this research that the nurses did spend a significant amount of time away from their supervisor. It was identified that in the absence of a supervisor, the student nurse was often supervised, either directly or indirectly, by another qualified member of staff. Although this may be a good short term solution, it is unlikely to be standardised across organisations and to only occur when there is an appropriate member of staff available. More strategic approaches to clinical supervision may be required such that practice and district nurses have appropriate support when it is required.
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The importance of supervisor availability has been highlighted within international research. For example, Saarikoski (2002) collected data from 558 student nurses who were based in both Finland and the UK. They completed the Clinical Learning Experience and Supervision Instrument. The Finish students were found to be significantly more positive regarding their clinical experience and their supervision relative to the UK students. This difference was found to be significantly associated with the fact that Finish students spent a significantly longer amount of time with their supervisor. This methodology benefits from using a relatively large sample. Other research has focussed on the extent to which the supervisors themselves are adequately supervised.
Aston et al (2001) conducted research which was commissioned by the English National Board. They collected information via documentation, one-to-one interviews and focus groups using samples of 76 lecturers and 46 practitioners. The research focused on the participants’ perceptions of the extent to which the supervisors of student nurses are adequately supervised, monitored and audited. It was found that supervisors believed that they were not sufficiently prepared, supported or monitored. They had a wide range of different experiences and they believed that there was a need for a more organised approach which would enable more consistent support and supervision to be available. It is important that the supervisors themselves are supervised so that they have someone to guide and advise them in their role and to provide them with the support that they need to effectively supervise their student nurses. The methodology used in this study benefits from having a relatively large sample and because it obtained data from a number of different sources. This facilitated an overall view of the topic to be gained by enabling a more comprehensive approach. This section has demonstrated that further work is required in the implementation of clinical supervision to ensure that both practice and district nurses, as well as their supervisors, are appropriately supervised.
5.3 EVALUATION OF THE OUTCOMES OF SUPERVISION PROGRAMMES
A key area of any evaluation will focus on the relevant outcomes. However, in terms of clinical supervision, this is not a straight forward task as there is a lack of clear and standardised assessment tools. Calman et al (2002) conducted 12 focus groups and 72 one-to-one interviews with nurses and supervisors to gain an understanding of their perceptions. It was reported that assessment tools were not seen to provide a fair reflection of a person’s ability and that the approaches taken varied significantly between organisations. As a result of this the research which has empirically assessed the effects of clinical supervision on both the quality of patient care and the nurses’ skill acquisition is limited.
Having said this, questionnaire research involving 19 nurses has highlighted some of the perceived positive outcomes of clinical supervision (Earnshaw 1995). The respondents indicated that the supervision provided vital support, aided their socialisation in terms of ward culture and facilitated their gaining of clinical experience which helped to improve their skills. Thus, through both direct and indirect methods, clinical supervision can have positive outcomes in terms of the nurses themselves. However, one cautionary note should be made here in that further research by Cahill (1996) has revealed that some nurses view clinical supervision as a form of control and assessment rather than a source of help to them.
Therefore, more standardised and validated assessment tools are required before confident conclusions can be made regarding the actual effects of clinical supervision on nurses’ skills and the quality of the care which they provide to their patients. There are some perceived outcomes of both a positive and negative nature which are associated with clinical supervision. Further work here would help to maximise and realise the perceived benefits and to minimise the effects of any possible negative aspects.
Other relevant research has focused on the outcomes of clinical supervision in terms of the nurses job satisfaction. Gray and Smith (2000) interviewed 10 nurses at five different points in their careers. A positive correlation was found between the quality of the supervisor/nurse relationship and the nurses’ satisfaction with their learning experience within their role. Therefore, if a positive relationship can be facilitated between a nurse and their supervision then this should, in theory, help to improve the chance that the nurse will be satisfied within their role. Research has also investigated the longer term aspects of the relationship between clinical supervision of the nurses’ satisfaction with their career. One such study was recently conducted by Pearcey and Elliott (2004) and involved interviews with 14 student nurses. Four key aspects were associated with whether or not the student nurses would be likely to go on and seek a career as a nurse in the future. These factors included ward culture, the reaction to negative incidents, the student nurses perceptions of the qualified nurses/supervisors and how these people were seen to treat the trainee nurses. Thus the supervisors can help to improve the learning experience in each of these areas.
This section has shown that improvements need to be made in establishing a standardised assessment to enable more accurate evaluations of the effectiveness of clinical supervision to take place. Nurse perceptions of clinical supervision do reveal that there are both positive and negative outcomes. One interesting finding merits consideration here. Andrew and Chilton (2000) interviewed supervisors and nurses regarding the benefits of a teaching qualification on the outcome of clinical supervision. The supervisors reported that they felt that it made them more effective in the supervisory role and that they provided better support as a result of the qualification. However, the nurses’ ratings of supervisors with and without a teaching qualifications revealed no significant differences. Thus more work is required in developing the training of supervisors to ensure that it has a positive effect.
This review has considered research which has evaluated clinical supervision within practice and district nursing. The discussion focussed on the development, implementation and the outcomes of clinical supervision. In terms of the developmental factors, a need for an improvement in the dissemination of standards was identified along with the establishment of clearer role definitions. A drive towards a more standardised approach to supervisor selection and training is also advocated. As for the implementation of clinical supervision, the need for both nurses and supervisors to be supervised was identified. Research has demonstrated that supervisor availability is associated with the nurse’s performance and hence it is important that supervisors are available as much as possible.
The final section of the discussion considered the outcomes of clinical supervision. The lack of standardised and validated assessment tools ensure that it is difficult to quantify the effects of clinical supervision on the nurses’ performances and ultimately on the quality of patient care. However, the perceived benefits of clinical supervision, such as support, socialisation, enabling clinical experience and enhancing job satisfaction, were identified. It may also have longer term benefits in terms of reducing the probability that a nurse will leave the profession. It is through working towards the realisation of the perceived benefits that clinical supervision can be made as effective as possible. Through this, more effective training programmes for clinical supervisors can be developed and the potentially negative view of clinical supervision as being about control and assessment can be replaced with a more positive image of aiding continuous improvement in nurse satisfaction and performance along with the quality of care which is given to patients.
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