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Implementing a system of structured clinical supervision with a group of DipHE(Nursing) RMN students
plementing a system of ructured clinical supervision ith a group of DipHE(Nursing) RMN students Vivien Markham and Peter Turner Clinical supervision is to become an integral part of mental health nursing, and the United Kingdom Central Council for Nursing, Midwifery & Health Visiting has recommended that it be incorporated in pre-registration education. This paper describes teachers' experiences of delivering a programme of clinical supervision education within the mental health branch of a diploma in nursing course. It outlines the implementation and evaluation of the programme, including discussion of the process and difficulties encountered. The programme appears to have provided a positive first experience for the students and to have given them the enthusiasm to adopt clinical supervision as part of their future roles as qualified practitioners.
Vivien Markham
BSc (Hons), CertEd, RMN, RNT, Lecturer in Health Studies Department of Health Studies. Peter Turner
MA, BA(Hons), BSc(Hons), RMN, RNT, Lecturer in Health Studies, Programmes Leader (Mental Health), Centre for Professional Development, Department of Health Studies, University of York, York District Hospital, Wigginton Road, York, UK (Requests for offprints to VM)
Manuscript accepted: 25 April 1996
32
Introduction
Background
The report of the Mental Health Nursing Review Team, Working in Partnership (Department of Health (DOH) 1994), was the first comprehensive evaluation of the role of the mental health nurse since 1968, and it made a series of major recommendations intended to guide the development of the profession. Perhaps one of the most significant was its belief that clinical supervision should be established as an integral part of practice up to and including the level of advanced practitioner (Recommendation 11, DOH 1994 p 22). To achieve such an outcome, the report proposed that student nurses should be introduced to the process of clinical supervision in professional training (DOH 1994 p 21). Such a perspective confirmed the value of an already established programme within the mental health branch of a diploma in nursing course, designed to familiarize students with a system of supervision, both paired and group. The intention was to enable students to experience its benefits with the hope that they would see its continued use as an essential part of future professional practice. This paper outlines the programme.
Definitions and descriptions of clinical supervision are limited within nursing literature, and there exists considerable confusion within the profession as to its exact nature. The term 'supervision' itself may not be helpful, with its implied elements of tight control, scrutiny and judgement. Indeed, the United Kingdom Central Council for Nursing, Midwifery & Health Visiting (UKCC), in its recent position statement on clinical supervision (UKCC 1995), questions the use of the term, suggesting 'clinical support' as a potentially more acceptable alternative. However, in general, leading advocates of the implementation of formal clinical support for staff have, to date, used the term 'clinical supervision' and defined it as 'an exchange between practising professionals to enable the development of professional skills' (Butterworth 1993, cited in Faugier & Butterworth 1994 p 9). Most would agree that having a forum for constructive exploration and discussion of a nurse's own practice is of benefit to both practitioner and clients. The distinction between counselling and supervision is sometimes misunderstood.
Nurse Education Today (1998)
18, 32-35
© 1998 Harcourt Brace & Co. Ltd
Teaching clinical supervision to RMN students
However, the main difference is seen to derive from the focus of each process. Whereas counselling would place emphasis on addressing personal problems and difficulties which might emanate from any aspect of an individual's life, supervision should be exclusively work-centred. It has to be acknowledged, however, that personal issues often play a significant part in a practitioner's ability to deliver quality care to clients, which is universally acknowledged as the ultimate goal of clinical supervision. As Kohner (1994) states, personal and private matters are not excluded from supervision, but must be relevant to the work experience under discussion. The close relationship between professional and personal qualities is acknowledged ... So a lot of supervision focuses on critiquing your inner self and bringing forward to the consciousness your motives and feelings (Kohner 1994 p 10). In many instances, supervision is given by the supervisee's line manager, or at least a practitioner of a higher grade, which may have advantages such as the potential for the supervisee to benefit from the greater knowledge, experience and expertise of the supervisor. However, there are also potential disadvantages, derived from the dual role element of the relationship, which might result in value conflicts (see Hawkins & Shohet 1989). The manager may be facilitative and supportive during one interview, yet be required to control or discipline their colleague during another. Additionally, the supervisee may feel intimidated, or uncomfortable at having to discuss practice difficulties which might be perceived as weaknesses. Anecdotal evidence suggests that managers may see supervision as a low priority and may find it difficult to invest the requisite amounts of time in their staff. The implementation of a system that sees the nurse teacher as a student nurse's supervisor carries the same potential benefits and disadvantages as managerial supervision. Paired peer supervision for students offers a means of overcoming some of the disadvantages. Faugier & Butterworth (1994) have recognized the usefulness of peer supervision for both practical and cost reasons. It has the potential to offer a safe, confidential environment in which to reflect on practice with the likelihood that both partners will have the time to invest and the motivation to help due to the reciprocal nature of the
© 1998 Harcourt Brace & Co. Ltd
relationship. The basic skills and qualities utilized in clinical supervision can be seen as those communication and interpersonal abilities being developed by RMN students throughout their training period as an essential part of their work with clients. Although students cannot be seen to be fully proficient in such skills before registration, they can be viewed as being adequately equipped to meet their own peer supervision needs given sufficient guidance and support by nurse teachers in the initial stages of the process. Nevertheless, perhaps the major disadvantage of the use of peer supervision with student nurses might still be seen to be their lack of pooled nursing experience and expertise. Consequently, its natural adjunct is facilitated group supervision in which nurse teachers participate in order to model both process and skills in addition to offering their wider experience.
Implementation In September 1993, a group of 14 RMN students commenced their 18-month branch programme. It was seen as desirable to establish with them a system of clinical supervision to enable them to reflect upon their practice and experience, and thereby facilitate both personal and professional development. The system was to include both paired peer supervision and facilitated group supervision. The length, duration and frequency of paired peer supervision would be controlled by the students themselves. Group supervision would be facilitated by their course leaders within college-based study time at 3-monthly intervals. The starting point was to introduce the group to the concept of clinical supervision, discuss potential advantages, examine potential barriers to its implementation and finally to elaborate a model of supervision which was seen as being particularly suited to meeting their needs. The chosen model was that of Dexter & Russell (1990, cited in Dexter & Wash 1995 p 87; see Fig. 1). It is based on the principles of humanistic counselling, and has a familiar problem-solving structure. Its attractions include its inbuilt contracting phase, flexibility, simplicity, and its invitation to supervisees to reflect upon successes and strengths in addition to problems and difficulties. Perhaps its main attribute in this particular context is its empowering, superviseeqed nature.
Nurse Education Today (1998) 18, 32-35
33
Teaching clinical supervision to RMN students
ACTIVE LISTENING
MUTUAL CONTRACTING
TRAINING & INFORMATION GIVING
PROBLEMS E ISSUES CONCERNS & W SITUATIONS O
ONE-TO-ONE
PEER ~
SELF R
RESOURCES &
GROUP
1
PLANNING
STRENGTHS QUALITIES TALENTS
K
SKILLS
GOAL
A
/
INTRA&
SETTING
INTERPERSONAL ISSUES
N A L
S
Y
N ~G
GENUINENESS Fig. I Aclient-centred model of supervision. Reproduced with kind permission of the Publishers Chapman and Hall Ltd, Dexter G, Wash M 1995 Psychiatric nursing skills: a patient centred approach, 2 edn, p 87.
In reviewing the model in detail with the students, issues discussed included the distinction between counselling and supervision, and the nature of concerns that might usefully be addressed by the supervision process. At the end of this first session, which was exclusively concerned with paired supervision, the students were invited to choose a peer supervision partner from within the group. To encourage the commencement of the process, they were asked to engage in the initial contracting phase of the relationship which included the arrangement of a first meeting date. Each student left the room with a summary handout copy of the model. They then had 6 weeks to familiarize themselves with the concept of supervision and to practise using the chosen model in pairs.
34
Nurse Education Today (1998) 18, 32-35
Six weeks into the students' first practice placement, they reflected on their supervisory experiences to date and were introduced to facilitated group supervision. It was established that although students would be addressing real issues, they would have to accept that attention to the process might intrude at times, since learning the skills of supervision was an equally important aspect of the programme. The whole group chose to divide into two smaller groups, each led by a teacher as facilitator, which concurred with Faugier & Butterworth's (1994 p 35) recommendation that the maximum number for group supervision should be 7 individuals. The contracting phase was utilized to establish subgroup ground rules. Students elected to take turns to explore issues. Teachers were prepared to bring issues to supervision to promote the process and to foster trust. After the separate small group sessions, the whole group reconvened to review collective experience in order to maximize learning. The 18-month branch programme incorporated 7 group supervision sessions. Although students reported the use of paired peer supervision on a regular basis and appeared to recognize its value, this was more difficult to monitor.
Evaluation Although the students professed to comprehend the chosen model after the initial didactic theoretical input, and were able to implement paired peer supervision with a measure of success during the period that preceded the first group session, it became apparent during the group supervision that some of its principles had perhaps not been fully accepted and internalized. Instead of following the model, the students, in their eagerness to help, tended to move straight into goal-setting or even to offering solutions before they had listened fully to the supervisee's issue. Consequently, group members were often working simultaneously with different stages of the model, confusing both themselves and the supervisee. At such times it was essential for the teacher as facilitator to intervene to identify problems of process. One of the major difficulties for group members was displaying the necessary skills to permit the process to be truly superviseeled. There was a tendency to lead the supervisees
© 1998 Harcourt Brace & Co. Ltd
Teaching clinical supervision to RMN students
or bombard them with questions. At this point, correct modelling by those in the group who had insight into the difficulty led to collective skills development. Despite such initial problems, the group responded quickly to guidance and demonstrated increasing competence. Students readily volunteered to be supervised, and remained motivated and committed to the enterprise. At the end of the course, the students' experience of supervision was specifically evaluated. Perceived benefits from the process included:
The one person who was not in receipt of supervision expressed ambivalent views towards its potential benefits in their current work situation. The exact nature of the respondent's reservations in this instance was unclear.
Conclusion
All group members expressed their belief in its value and indicated that they intended to continue to use supervision in their careers as registered practitioners, regardless of whether or not it was offered or expected by management. Some had already made commitments to a supervision partner within the group to continue after leaving the course. The group appeared to have positively embraced the supervision programme.
Clinical supervision is likely to increasingly become an integral part of mental health nursing and it would therefore seem essential to prepare RMN students for this part of their work. Some confusion seems to surround the profession's understanding of the concept, and its adoption has been sporadic. Resistance on the part of those involved in caring to engage in the process has been evident for a range of reasons, including previous bad experiences of its implementation (Hawkins & Shohet 1989). As a consequence, if its value is accepted, it would seem crucial to ensure that a practitioner's first experience of supervision is positive so that a commitment to its future use ensues. This paper has outlined a programme that appears to have provided such a positive first experience for a group of student mental health nurses and given them the necessary enthusiasm to adopt clinical supervision in seeking to enhance the quality and effectiveness of their future practice.
Post-course evaluation
References
Six months after their completion of the mental health nurse diploma course, members of the subject group were sent a questionnaire designed to review their post-registration experience of supervision. From the original group of 14, there were 8 respondents, 6 of whom were employed in mental health care settings. The other 2 had not yet secured employment. Five people suggested that they were actively involved in an ongoing system of supervision. They had all entered the process with enthusiasm and indicated that their previous experience of supervision in nurse training had influenced their positive attitude.
Department of Health 1994 Working in partnership. A collaborative approach to care. Report of the Mental Health Nursing Review Team. HMSO, London Dexter G, Wash M 1995 Psychiatric nursing skills. A patient-centred approach, 2nd ed. Chapman & Hall, London Faugier J, Butterworth C A 1994 Clinical supervision: a position paper. School of Nursing Studies, University of Manchester Hawkins P, Shohet R 1989 Supervision in the helping professions. Open University Press, Milton Keynes Kohner N 1994 Clinical supervision in practice. Nursing Development Units, Kings Fund Centre, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1995 Clinical supervision for nursing and health visiting. Registrar's letter 4/1995
• • • •
Increased group cohesion Feelings of being supported Greater mutual respect Satisfaction at having helped and having been helped • Enhanced communication and counselling skills.
© 1998 Harcourt Brace & Co. Ltd
Nurse Education Today (1998) 18, 32-35
35
Vivien Markham
BSc (Hons), CertEd, RMN, RNT, Lecturer in Health Studies Department of Health Studies. Peter Turner
MA, BA(Hons), BSc(Hons), RMN, RNT, Lecturer in Health Studies, Programmes Leader (Mental Health), Centre for Professional Development, Department of Health Studies, University of York, York District Hospital, Wigginton Road, York, UK (Requests for offprints to VM)
Manuscript accepted: 25 April 1996
32
Introduction
Background
The report of the Mental Health Nursing Review Team, Working in Partnership (Department of Health (DOH) 1994), was the first comprehensive evaluation of the role of the mental health nurse since 1968, and it made a series of major recommendations intended to guide the development of the profession. Perhaps one of the most significant was its belief that clinical supervision should be established as an integral part of practice up to and including the level of advanced practitioner (Recommendation 11, DOH 1994 p 22). To achieve such an outcome, the report proposed that student nurses should be introduced to the process of clinical supervision in professional training (DOH 1994 p 21). Such a perspective confirmed the value of an already established programme within the mental health branch of a diploma in nursing course, designed to familiarize students with a system of supervision, both paired and group. The intention was to enable students to experience its benefits with the hope that they would see its continued use as an essential part of future professional practice. This paper outlines the programme.
Definitions and descriptions of clinical supervision are limited within nursing literature, and there exists considerable confusion within the profession as to its exact nature. The term 'supervision' itself may not be helpful, with its implied elements of tight control, scrutiny and judgement. Indeed, the United Kingdom Central Council for Nursing, Midwifery & Health Visiting (UKCC), in its recent position statement on clinical supervision (UKCC 1995), questions the use of the term, suggesting 'clinical support' as a potentially more acceptable alternative. However, in general, leading advocates of the implementation of formal clinical support for staff have, to date, used the term 'clinical supervision' and defined it as 'an exchange between practising professionals to enable the development of professional skills' (Butterworth 1993, cited in Faugier & Butterworth 1994 p 9). Most would agree that having a forum for constructive exploration and discussion of a nurse's own practice is of benefit to both practitioner and clients. The distinction between counselling and supervision is sometimes misunderstood.
Nurse Education Today (1998)
18, 32-35
© 1998 Harcourt Brace & Co. Ltd
Teaching clinical supervision to RMN students
However, the main difference is seen to derive from the focus of each process. Whereas counselling would place emphasis on addressing personal problems and difficulties which might emanate from any aspect of an individual's life, supervision should be exclusively work-centred. It has to be acknowledged, however, that personal issues often play a significant part in a practitioner's ability to deliver quality care to clients, which is universally acknowledged as the ultimate goal of clinical supervision. As Kohner (1994) states, personal and private matters are not excluded from supervision, but must be relevant to the work experience under discussion. The close relationship between professional and personal qualities is acknowledged ... So a lot of supervision focuses on critiquing your inner self and bringing forward to the consciousness your motives and feelings (Kohner 1994 p 10). In many instances, supervision is given by the supervisee's line manager, or at least a practitioner of a higher grade, which may have advantages such as the potential for the supervisee to benefit from the greater knowledge, experience and expertise of the supervisor. However, there are also potential disadvantages, derived from the dual role element of the relationship, which might result in value conflicts (see Hawkins & Shohet 1989). The manager may be facilitative and supportive during one interview, yet be required to control or discipline their colleague during another. Additionally, the supervisee may feel intimidated, or uncomfortable at having to discuss practice difficulties which might be perceived as weaknesses. Anecdotal evidence suggests that managers may see supervision as a low priority and may find it difficult to invest the requisite amounts of time in their staff. The implementation of a system that sees the nurse teacher as a student nurse's supervisor carries the same potential benefits and disadvantages as managerial supervision. Paired peer supervision for students offers a means of overcoming some of the disadvantages. Faugier & Butterworth (1994) have recognized the usefulness of peer supervision for both practical and cost reasons. It has the potential to offer a safe, confidential environment in which to reflect on practice with the likelihood that both partners will have the time to invest and the motivation to help due to the reciprocal nature of the
© 1998 Harcourt Brace & Co. Ltd
relationship. The basic skills and qualities utilized in clinical supervision can be seen as those communication and interpersonal abilities being developed by RMN students throughout their training period as an essential part of their work with clients. Although students cannot be seen to be fully proficient in such skills before registration, they can be viewed as being adequately equipped to meet their own peer supervision needs given sufficient guidance and support by nurse teachers in the initial stages of the process. Nevertheless, perhaps the major disadvantage of the use of peer supervision with student nurses might still be seen to be their lack of pooled nursing experience and expertise. Consequently, its natural adjunct is facilitated group supervision in which nurse teachers participate in order to model both process and skills in addition to offering their wider experience.
Implementation In September 1993, a group of 14 RMN students commenced their 18-month branch programme. It was seen as desirable to establish with them a system of clinical supervision to enable them to reflect upon their practice and experience, and thereby facilitate both personal and professional development. The system was to include both paired peer supervision and facilitated group supervision. The length, duration and frequency of paired peer supervision would be controlled by the students themselves. Group supervision would be facilitated by their course leaders within college-based study time at 3-monthly intervals. The starting point was to introduce the group to the concept of clinical supervision, discuss potential advantages, examine potential barriers to its implementation and finally to elaborate a model of supervision which was seen as being particularly suited to meeting their needs. The chosen model was that of Dexter & Russell (1990, cited in Dexter & Wash 1995 p 87; see Fig. 1). It is based on the principles of humanistic counselling, and has a familiar problem-solving structure. Its attractions include its inbuilt contracting phase, flexibility, simplicity, and its invitation to supervisees to reflect upon successes and strengths in addition to problems and difficulties. Perhaps its main attribute in this particular context is its empowering, superviseeqed nature.
Nurse Education Today (1998) 18, 32-35
33
Teaching clinical supervision to RMN students
ACTIVE LISTENING
MUTUAL CONTRACTING
TRAINING & INFORMATION GIVING
PROBLEMS E ISSUES CONCERNS & W SITUATIONS O
ONE-TO-ONE
PEER ~
SELF R
RESOURCES &
GROUP
1
PLANNING
STRENGTHS QUALITIES TALENTS
K
SKILLS
GOAL
A
/
INTRA&
SETTING
INTERPERSONAL ISSUES
N A L
S
Y
N ~G
GENUINENESS Fig. I Aclient-centred model of supervision. Reproduced with kind permission of the Publishers Chapman and Hall Ltd, Dexter G, Wash M 1995 Psychiatric nursing skills: a patient centred approach, 2 edn, p 87.
In reviewing the model in detail with the students, issues discussed included the distinction between counselling and supervision, and the nature of concerns that might usefully be addressed by the supervision process. At the end of this first session, which was exclusively concerned with paired supervision, the students were invited to choose a peer supervision partner from within the group. To encourage the commencement of the process, they were asked to engage in the initial contracting phase of the relationship which included the arrangement of a first meeting date. Each student left the room with a summary handout copy of the model. They then had 6 weeks to familiarize themselves with the concept of supervision and to practise using the chosen model in pairs.
34
Nurse Education Today (1998) 18, 32-35
Six weeks into the students' first practice placement, they reflected on their supervisory experiences to date and were introduced to facilitated group supervision. It was established that although students would be addressing real issues, they would have to accept that attention to the process might intrude at times, since learning the skills of supervision was an equally important aspect of the programme. The whole group chose to divide into two smaller groups, each led by a teacher as facilitator, which concurred with Faugier & Butterworth's (1994 p 35) recommendation that the maximum number for group supervision should be 7 individuals. The contracting phase was utilized to establish subgroup ground rules. Students elected to take turns to explore issues. Teachers were prepared to bring issues to supervision to promote the process and to foster trust. After the separate small group sessions, the whole group reconvened to review collective experience in order to maximize learning. The 18-month branch programme incorporated 7 group supervision sessions. Although students reported the use of paired peer supervision on a regular basis and appeared to recognize its value, this was more difficult to monitor.
Evaluation Although the students professed to comprehend the chosen model after the initial didactic theoretical input, and were able to implement paired peer supervision with a measure of success during the period that preceded the first group session, it became apparent during the group supervision that some of its principles had perhaps not been fully accepted and internalized. Instead of following the model, the students, in their eagerness to help, tended to move straight into goal-setting or even to offering solutions before they had listened fully to the supervisee's issue. Consequently, group members were often working simultaneously with different stages of the model, confusing both themselves and the supervisee. At such times it was essential for the teacher as facilitator to intervene to identify problems of process. One of the major difficulties for group members was displaying the necessary skills to permit the process to be truly superviseeled. There was a tendency to lead the supervisees
© 1998 Harcourt Brace & Co. Ltd
Teaching clinical supervision to RMN students
or bombard them with questions. At this point, correct modelling by those in the group who had insight into the difficulty led to collective skills development. Despite such initial problems, the group responded quickly to guidance and demonstrated increasing competence. Students readily volunteered to be supervised, and remained motivated and committed to the enterprise. At the end of the course, the students' experience of supervision was specifically evaluated. Perceived benefits from the process included:
The one person who was not in receipt of supervision expressed ambivalent views towards its potential benefits in their current work situation. The exact nature of the respondent's reservations in this instance was unclear.
Conclusion
All group members expressed their belief in its value and indicated that they intended to continue to use supervision in their careers as registered practitioners, regardless of whether or not it was offered or expected by management. Some had already made commitments to a supervision partner within the group to continue after leaving the course. The group appeared to have positively embraced the supervision programme.
Clinical supervision is likely to increasingly become an integral part of mental health nursing and it would therefore seem essential to prepare RMN students for this part of their work. Some confusion seems to surround the profession's understanding of the concept, and its adoption has been sporadic. Resistance on the part of those involved in caring to engage in the process has been evident for a range of reasons, including previous bad experiences of its implementation (Hawkins & Shohet 1989). As a consequence, if its value is accepted, it would seem crucial to ensure that a practitioner's first experience of supervision is positive so that a commitment to its future use ensues. This paper has outlined a programme that appears to have provided such a positive first experience for a group of student mental health nurses and given them the necessary enthusiasm to adopt clinical supervision in seeking to enhance the quality and effectiveness of their future practice.
Post-course evaluation
References
Six months after their completion of the mental health nurse diploma course, members of the subject group were sent a questionnaire designed to review their post-registration experience of supervision. From the original group of 14, there were 8 respondents, 6 of whom were employed in mental health care settings. The other 2 had not yet secured employment. Five people suggested that they were actively involved in an ongoing system of supervision. They had all entered the process with enthusiasm and indicated that their previous experience of supervision in nurse training had influenced their positive attitude.
Department of Health 1994 Working in partnership. A collaborative approach to care. Report of the Mental Health Nursing Review Team. HMSO, London Dexter G, Wash M 1995 Psychiatric nursing skills. A patient-centred approach, 2nd ed. Chapman & Hall, London Faugier J, Butterworth C A 1994 Clinical supervision: a position paper. School of Nursing Studies, University of Manchester Hawkins P, Shohet R 1989 Supervision in the helping professions. Open University Press, Milton Keynes Kohner N 1994 Clinical supervision in practice. Nursing Development Units, Kings Fund Centre, London United Kingdom Central Council for Nursing, Midwifery & Health Visiting 1995 Clinical supervision for nursing and health visiting. Registrar's letter 4/1995
• • • •
Increased group cohesion Feelings of being supported Greater mutual respect Satisfaction at having helped and having been helped • Enhanced communication and counselling skills.
© 1998 Harcourt Brace & Co. Ltd
Nurse Education Today (1998) 18, 32-35
35