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Examining the benefits of professional clinical supervision: professional clinical supervision has many benefits for nurses. These include providing time to reflect on practice, promoting professional accountability and providing some stress relief.

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Nursing, by its very nature, exposes all nurses to various challenges and potential stressors in their working lives. Over the years, the profession has focused on stress management, better communication within teams, and practical ways to improve work-life balance, to help nurses cope better with workplace stress. (1)

More recently, in the United Kingdom (UK) and the United States (US), professional clinical supervision (also referred to as clinical supervision) has been promoted as an important strategy to support nurses, as well as a process to enhance patient care and promote ongoing professional development. (2)

Professional clinical supervision is not welt established in many nursing services in New Zealand and Australia, so it is timely to evaluate what it has to offer nursing. (2) Nurses working in mental health services have embraced professional clinical Supervision as a key method for refining and learning therapeutic interpersonal skills. (3) Participating in clinical supervision is included in the mental health nursing competencies for nursing registration. (4) Many senior nurses working in mental health are involved in receiving and providing professional clinical supervision for their nursing colleagues. However, this article focuses on the role of professional clinical supervision outside mental health services. Professional clinical supervision has value for all nurses, but this article advocates that professional clinical supervision is extremely beneficial for senior clinical nurses, who usually work in separate, autonomous, clinically-based roles and don't always have the support of close colleagues or a work team.

For the context of this article, senior nurses include those who work in a specialist rote in clinical practice, eg clinical nurse specialists and case managers, and those working in clinically or service-based education roles, eg clinical nurse educators. To clarify the process of professional clinical supervision, the article firstly discusses what it is, and the process involved for nurses. The benefits of professional clinical supervision for senior nurses will be analysed with reference to current literature and, finally, issues related to access to professional clinical supervision are identified.

What is professional clinical supervision?

Many definitions of professional clinical supervision have been proposed since it was first developed in the disciplines of social work and counselling. Most definitions view it as a process of in-depth reflection by practitioners on their work, in order that they continue to learn and develop from their experiences. (3,5) It has been suggested the purpose of professional clinical supervision is to improve nursing practice, so it needs to focus on nurse-patient interactions. (6)

Professional clinical supervision has been described as having three functions. (7) Firstly, the "formative" function, where the process has an educative role. Secondly, the "normative" function, where professional clinical supervision helps develop a consistency of approach to patient care, ie it follows "norms" of nursing practice. Thirdly, there is a "restorative" function, which provides support and validation for the person receiving supervision through peer feedback. (2) Professional clinical supervision can occur in small groups or on a one-to-one basis.

The following definition encompasses these key elements by describing professional clinical supervision as "a designated reflective exchange between two or more professionals in a safe and supportive environment, which critically analyses practice through normative, formative and restorative means to promote and enhance the quality of patient care". (8)

Professional clinical supervision helps nurses discuss patient care in a supportive setting and provides feedback from their supervisor or colleagues, which helps improve their understanding of clinical issues. (2) Through sharing experiences, they realise they are not alone in their feelings and perceptions. This provides support and validation for them, both personally and professionally. However, it is not personal counselling nor mentoring, nor a performance management strategy. (9)

Nurses will get the most out of professional clinical supervision if they prepare themselves by reflecting on the patient care they have provided. (6) Writing an exemplar in a personal journal soon after a "critical incident" will capture their thoughts, feelings and actions most vividly. Sharing this exemplar with their supervisor, or with colleagues in a group supervision session, gives an opportunity for discussion on what occurred and why, fosters a self-critique of practice and how this learning can be used again. Other areas that provide topics for supervision are: areas of responsibility in your work; stress that is influencing your work; and how you are developing in your role. (3)

Building rapport and trust

Nurses who prepare themselves for supervision by accessing some training or reading about supervision in the Literature, are more likely to find the process effective. (10) For nurses new to supervision, it is natural to feel some uncertainty about the process, about how much they are willing to reveal about their practice, and how much they can trust their supervisor. Therefore, it is useful to meet more frequently at first, eg every two to three weeks, so the supervisor and nurse receiving supervision (supervisee) can get to know each other and build rapport and trust. Some nurses may need to meet several supervisors before they feel they can build a relationship with one supervisor. An experienced supervisor will always ask for feedback on the process and regular evaluation ensures the nurse's needs/goals are being met. (6) If this evaluation is overlooked, then relationships that are routine, mechanical or fraught With anxiety can develop, and they are less effective. (11)

Over the past five years in New Zealand, there has been a large incease in the number of senior nurse positions in district health boards (DHB) and non-government organisations (NGO) providing nursing services. These roles provide a specialist nursing service, with a clinical and/or educative focus, eg breast care nurses, nurse educators in surgical services. Many senior nurses have set up nurse-led clinics, extended nursing services in innovative ways, or developed specialist continuing education programmes.

Although senior nurses work collegially With doctors, other nurses and members of the multidisciplinary team, they practise specialist nursing and education autonomously. They are often working in advanced practice roles, where the boundaries between medical and nursing roles blur, and expectations of their roles can vary and conflicts may occur. They may have had to set up their rote and argue for essential resources, eg clinic/office space, computer and cell phone and for financial support for postgraduate study. In smaller DHBs, there may be fewer senior nurses, so collegial support can be limited, and they may feel more isolated. As nurses go up the hierarchical scale, they experience more stress, have less time and more responsibility and become more isolated. (12) Professional clinical supervision, particularly in small groups, can be beneficial in providing support for senior nurses working in isolation, and enhance communication and networking. (13) It can also provide effective management of conflict, both professionally and organisationally, which, again, reduces stress. (2,13) Overall, professional clinical supervision can increase nurses' job satisfaction. (14)

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One of the key benefits of professional clinical supervision, is the process of facilitated reflection on one's practice, with the aim of improving patient outcomes. (6) This is particularly important for senior nurses, as they are often developing new service initiatives and acting as change agents. Implementing change can often create challenges and stress, which can be minimised by the reflective process in professional clinical supervision. (15)

Complex situations

Senior nurses are also dealing with complex patient/family situations and professional clinical supervision provides a way of learning from the knowledge and experiences of others. (13) The community palliative care service where I worked had a fortnightly group supervision session, where we reflected on and discussed challenging or complex patient situations we had experienced. This forum enabled me to discuss issues and situations in a safe, non-judgmental environment, and the others' contributions provided me with additional information, guidance and support. Using Proctors framework, (7) the discussions always provided further education and met the "formative" function. As we discussed standards of practice or how we approached complex family dynamics, the "normative" function was apparent. However, the opportunity to talk about one's feelings and thoughts after difficult interactions related to death, dying, grief and loss was invaluable in reducing the burden of care, thus meeting the "restorative" function. Meeting in this way also promoted supportive, cohesive team work. (13) However, for many senior nurses, small group supervision is not an option, and one-to-one professional clinical supervision is very beneficial. (6)

If we accept the view that professional clinical supervision has significant benefits for senior nurses, then why is this process not freely available and accessible? NZNO's position statement on professional and clinical supervision states "professional and clinical supervision is essential for all nurses and midwives". (9) NZNO also recommends that professional and clinical supervision is available and accessible to nurses and midwives. (9) Some of the reasons professional clinical supervision is not readily available can be explained by resourcing constraints within nursing services and competing priorities. Senior nurses would need access to trained external clinical supervisors and, ideally, attend training in being a supervisee. Funding is required to pay for supervisor training, for on-going supervision sessions and also to release nurses from work.

Those against professional clinical supervision for nurses argue that research has not yet demonstrated significant benefits for the costs involved. However, a body of evidence is emerging that indicates professional clinical supervision provides peer support and stress relief for nurses, as well as promoting professional accountability and knowledge development. (2) The costs of burnout and compassion fatigue are not easily accounted for, but the costs of sick leave and stress-related attrition from nursing provide some clear evidence for professional clinical supervision. (16)

Under the New Zealand Health and Safety in Employment Amendment Act 2003, employers are required to "take 'reasonable steps" to safeguard employees from harm related to workplace stress". (17) It has been argued that, in order to avoid compassion fatigue, nurses need to experience caring and restoration, which can be provided in professional clinical supervision. (16) Too much caring without restoration has been a key factor reading to burnout. (18) The Nursing Council has already recognised these benefits for nurse practitioners, who are required to participate in regular, format professional clinical supervision with an appropriate supervisor. (19)

It is very heartening that in some DHBs and NGOs, resources have been allocated to provide professional clinical supervision for nurses. A variety of models are being explored, pirated and implemented to meet the needs of nurses, using the resources available. It is beyond the scope of this article to discuss these initiatives in depth, but many senior nurses, nurse managers and directors of nursing are working hard to promote and provide professional clinical supervision and to increase the funding available to support it.

Another reason professional clinical supervision is not accessed, relates to the negative perceptions of many nurses, who remember the "snoopervision" focus on clinical practice many years ago. (16) Then, the focus was on clinical education, where nurses were monitored and corrected, in an effort to improve standards and promote conformity. (16) As more nurses read about, talk about, share experiences and receive training about professional clinical supervision, hopefully these negative attitudes will change.

On a personal note, as a nurse who is receiving external professional clinical supervision, I support the functions that Proctor has identified in the supervision process. (7) Having protected time to reflect on issues experienced in my clinical practice in a safe, supported setting has been invaluable. It has opened my eyes to possibilities of improving my practice (normative function); my self-awareness, reflective practice and knowledge have increased (formative function); and better ways of coping with compassion fatigue are developing (restorative function). From my own experience, I can see that professional clinical supervision has many benefits for senior nurses and this is also supported in the literature. (13,17) If you are a senior nurse not receiving professional clinical supervision, but would like more professional support, then I recommend you talk to your manager and negotiate access to on-going supervision. I believe it's a process you will find positive and not regret.

Conclusion

Senior nurses often work in autonomous, clinically based rotes and may not have the support of close colleagues or a work team to discuss their practice, their successes, conflicts or challenges. Professional clinical supervision has been proposed as having many benefits for senior nurses, particularly in promoting reflection on practice, promoting professional accountability, further developing skills and knowledge, and providing support and stress relief. There are several reasons why senior nurses have difficulty accessing clinical supervision. These include: access to training; limited funding; access to external supervisors; and negative perceptions about the process. Many nursing services in DHBs and NGOs are improving access to professional clinical supervision but senior nurses are their own best advocates in ensuring this important service is open to them.

* Acknowledgement: Thanks to the clinical nurse manager of Nurse Maude Hospice palliative care service, Jane Rollings, and director of nursing at Nurse Maude, Sheree East, for their comments on this article.

This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in October 2008.

Jackie Walker, RN, MN, (Palliative care), BA (Nsg), MEd, DipTching (Tertiary), has two part-time research nurse positions: one in the palliative care service at Nurse Maude Hospice, Christchurch; and the other at the New Zealand Institute of Community Health Care at Nurse Maude. She also provides a professional clinical supervision and academic reentering service to nurses in Christchurch.

References

(1) Vachon, M. (2003) Occupational stress in Palliative Care in M. O'Connor & S. Aranda (Eds.), Palliative Care Nursing: a guide to practice. Melbourne: Ausmed Publications ply Ltd.

(2) Brunero, S. & Stein-Parbury, J. (2008) The effectiveness of clinical supervision in nursing: an evidence based literature review. Australian Journal of Advanced Nursing; 25: 3, 86-94.

(3) Bond, M. & Holland, S. (1998) Skill of clinical supervision for nurses. Philadelphia: Open University Press.

(4) Nursing Council of New Zealand. (2002) Competencies for entry to the register of Comprehensive Nurses. Wellington: Author

(5) Procter, B. (2001) Training for the supervision alliance attitude, skills and intention. In J. R. Cutliffe, T. Butterworth & B. Procter (Eds.), Fundamental themes in clinical supervision. London: Routledge.

(6) Van Ooijen, E. (2000) Clinical supervision: n practical guide. Edinburgh: Churchill Livingstone.

(7) Procter, B. (1986) Supervision: a co-operative exercise in accountability. In M. Marken and M. Payne (Eds.), Enabling and Ensuring. Leicester, UK: Leicester National Youth Bureau and Council for Education and Training in Youth and Community Work.

(8) Howatson-Jones, I. L. (2003) Difficulties in clinical supervision and Lifelong learning. Nursing Standard; 17: 37, 37-41.

(9) New Zealand Nurses Organisation. (2008) Professional and Clinical Supervision position statement. Wellington: Author.

(10) Davys, A. (2002) Perceptions through a prism: Three accounts of good social work supervision. Cited in D. Wepa (Ed.), (2007) Clinical Supervision in Aotearoa/New Zealand--A health perspective. Auckland: Pearson Education New Zealand.

(11) Jones, A. (2001) The influence of professional rotes on clinical supervision. Nursing Standard; 15: 33, 42-45.

(12) Duarri, W. & Kendrick, K. (1999) Implementing clinical supervision. Professional Nurse; 14: 12, 849-852.

(13) Turner, K., Laut, S., Kempster, J. & Nolan, S. (2005) Group clinical supervision: supporting neurology clinical nurse specialists in practice. Journal of Community Nursing; 19: 9, 4-8.

(14) Butterworth, T. et.al. (1997) Clinical supervision and mentorship. It's good to talk: An evaluation study in England and Scotland. Manchester: University of Manchester.

(15) Hawkins, P. & Shohet, R. (2000) Supervision in the helping professions: an individual, group and organisational approach. (2nd ed.) United Kingdom: Open University Press.

(16) Meyer, M. (2007) Who cares about nurses: contradictions in clinical supervision. In B. Wepa (Ed.), Clinical Supervision in Aotearoa/New Zealand--A health perspective. Auckland: Pearson Education New Zealand.

(17) Howard, F. (2007) Keeping ourselves "well at work"--managing stress and creating well-being in clinical supervision. In D. Wepa (Ed.), Clinical Supervision in Aoteoroa/New Zealand--A health perspective. Auckland: Pearson Education New Zealand.

(18) Wright, S. G & Sayre-Adams, J. (2000) Sacred space: Right relationship and spirituality in health care. London: Churchill Livingstone.

(19) Nursing Council of New Zealand. (2000) Competencies for Nurse Practitioner Scope of Practice. Wellington: Author
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Title Annotation:VIEWPOINT
Author:Walker, Jackie
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Jun 1, 2009
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