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Clinical supervision in a challenging behaviour unit

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Aim: As part of an ongoing service development programme at St Andrew’s Hospital, Northampton, it was identified that it would be beneficial to explore whether qualified nursing staff in the hospital’s five clinical divisions were satisfied with the clinical supervision they received. Also, the survey examined whether supervision was of good quality, was suitable for different specialist environments and if it affected motivation, skills, confidence and stress levels. The survey also explored if there was a difference between D or E-grade nurses and nurses who are F grade and above regarding their perception of clinical supervision.

Abstract

VOL: 101, ISSUE: 47, PAGE NO: 32

Stewart Carney, MSc, BSc, RMN, is senior nurse practice development, St Andrew’s Hospital, Northampton

Aim: As part of an ongoing service development programme at St Andrew’s Hospital, Northampton, it was identified that it would be beneficial to explore whether qualified nursing staff in the hospital’s five clinical divisions were satisfied with the clinical supervision they received. Also, the survey examined whether supervision was of good quality, was suitable for different specialist environments and if it affected motivation, skills, confidence and stress levels. The survey also explored if there was a difference between D or E-grade nurses and nurses who are F grade and above regarding their perception of clinical supervision.

 

 

Method: This included a Likert scaled questionnaire (Ladany et al, 1996); and a retrospective (ex-post-facto) cross-sectional survey design. A questionnaire and information sheet was dispatched to 50 qualified nursing staff. Ten nurses from each of the five divisions were invited to participate. After one month, 35 (70 per cent) had returned the questionnaires.

 

 

Results: Senior staff benefit more and are more satisfied with regular supervision than junior staff. The survey shows that clinical supervision is in quite good shape, with most nurses receiving regular supervision within a limited time span.

 

 

Conclusion: Large numbers of qualified nurses receive supervision in the hospital and this is extremely positive. However, there are a number of discrepancies regarding who receives supervision, and within what time frame, and why so many qualified nurses feel the supervision is not helping them work more effectively.

 

 

Clinical supervision is a broad concept, having been adopted by and integrated into many caring professions. Definitions tend to delimit the boundaries, range, role and depth of supervision. In nursing, clinical supervision definitions tend to encompass aspects of learning, interpersonal support and oversight but not all authors agree on this basic summation (Fowler, 1996). The NMC (2004) has acknowledged the need for a range of definitions and models to address the diversity of practice within nursing and these can include training days stipulated by PREP.

 

 

At St Andrew’s Hospital, clinical supervision has commitment from all levels in the organisation from practitioners through to the chief executive, but it requires time, funding, staff and training. The hospital has a clinical supervision foundation course, which has successfully trained 191 registered nurses in the Proctor model (1986) of supervision (Fig 1).

 

 

The Proctor model concentrates on the philosophy of clinical supervision as not something you do to a colleague or that a colleague does to you but a two-way, cooperative process that emphasises interpersonal support (Raffert and Coleman, 1996).

 

 

The Proctor model is known as a function model, or three-functional model, because it deals with the formative, restorative and normative functions of clinical supervision. This model is useful in getting supervision started, where those being supervised may be unsure what to talk about or how to prepare. This model should be applicable in all areas of nursing and therefore should be suitable for forensic and challenging behaviour units at St Andrew’s.

 

 

Method
Setting for the survey

 

 

St Andrew’s is a charitable status hospital based in Northamptonshire. The hospital provides specialist secure mental health care to approximately 500 inpatients with mental illness, learning disabilities and acquired brain injury diagnoses. It employs approximately 430 registered nurses.

 

 

The hospital has five divisions:

 

 

- Adult forensic, which consists of seven wards (104 nurses work within this division);

 

 

- Adolescent forensic, which consists of five wards (81 nurses work on this division);

 

 

- Adult brain injury, which consists of one large unit with different areas for the severity of the injury (86 nurses work within this division);

 

 

- Adults with mild learning disabilities and challenging behaviours and young people with similar problems, which consists of four wards (80 nurses work on this division);

 

 

- Care and treatment of older patients, which consists of six wards (83 nurses work in this division).

 

 

The survey

 

 

The method used a retrospective (ex-post-facto) cross-sectional design and a Likert scaled supervision questionnaire (Ladany et al, 1996). An information sheet and guidelines were attached to it.

 

 

This questionnaire was selected because:

 

 

- It was a modified vision of the clinical supervision questionnaire - the Supervision Satisfaction Questionnaire (SSQ) (Larsen et al, 1979). The terms counselling and services were replaced with the term supervision;

 

 

- The SSQ model asks participants to use a four-point scale ranging from low (1) to high (4) to rate their satisfaction with various aspects of their supervision;

 

 

- The SSQ contains eight items altogether. Therefore, total scores range from eight to 32, with higher scores reflecting greater satisfaction;

 

 

- The questionnaire has been shown to be related to patients and therapists/nurses;

 

 

- The Ladany et al (1996) questionnaire is a validated questionnaire (Cottrell, 1996).

 

 

Questions 1-10 measure the satisfaction of nurses, using an established scoring tool designed by Ladany et al (1996). Questions 11-20 concentrate on aspects of nursing that relate to St Andrew’s Hospital and the Proctor model. These questions were designed to assess confidence and motivation after supervision, and whether supervision affected skills and ability to cope with stress. This questionnaire was dispatched to every potential participant in all five divisions.

 

 

The ex-post-facto approach was chosen in conjunction with a satisfaction questionnaire. This was used as the main vehicle to gather relevant phenomenological detail relating to questions. Ex post facto, meaning ‘retrospectively’ is a well-validated method (Cohen and Manion, 1987) and is particularly useful in identifying antecedents of events that have happened as it cannot be engineered or manipulated. One of the limitations of an ex-post-facto design is it is often difficult to find similar or matching groups statistically but, because St Andrew’s Hospital has five divisions posing similar challenges, it was an ideal design to use.

 

 

The survey included full-time nurses. Health care assistants and agency nurses were excluded.Approval was sought from Northampton medical research/ethics committee and the survey coordinator took into account autonomy methodology and the Data Protection Act (1998).

 

 

Results
Of the 50 questionnaires 35 (70 per cent) were returned and out of these 14 (40 per cent) respondents were F grade and above compared with 21 (60 per cent) D or E grades.

 

 

The overall (mean) satisfaction with clinical supervision as measured using the Ladany et al (1996) SSQ (items 3-10) in the survey was 25.54 (range 18-32, SD=3.87). F grades and above were significantly more satisfied with their clinical supervision using this measure, than were D or E grades.

 

 

When nurses were asked about their feelings regarding satisfaction with clinical supervision, eight (23 per cent) F grades and above scored in the highest category 30-32 and only one (three per cent) D or E grade scored in the same category. Thirteen (37 per cent) D or E grades and four (11 per cent) F grades and above scored 20-24. Six (17 per cent) D or E-grade nurses and one (three per cent) F grade and above scored 25-29. There was one (three per cent) F grade and above and one (three per cent) D or E grade who scored in the least satisfied group of 15-19 (Fig 2).

 

 

Satisfaction survey data

 

 

The survey showed that each division had returned generally equal numbers of questionnaires, with adult forensic mental health returning the most with eight and the learning disability service the least with five. Also, 100 per cent of participants had received clinical supervision while employed at the hospital and out of these, 29 nurses - 17 D or E grade and 12 F and above - had received supervision within a three-month period.

 

 

A total of 20 nurses, 15 D or E grade and five F grade and above, stated they received good-quality supervision. None reported having poor-quality supervision. A total of 23 staff, 20 D or E and six F grades and above, stated they received the kind of supervision they wanted. A total of 32 staff, 20 D or E and 12 F grade and above, said supervision kept their skills up to date within their work environment.

 

 

A total of 19 nurses, 11 D or E and eight F and above, said supervision had fitted in well with their ward-based needs and 33 staff, 19 D or E and 14 F and above, stated that they would recommend their supervisor to a colleague. A total of 32 staff, 18 D or E and 14 F and above, said that if they were to leave the hospital and return at a later date, they would seek the same supervisor. And 24 staff stated that supervision had helped them in stressful situations on the ward, with the emphasis on more junior staff, with 18 D or E grades compared with six F grades and above replying.

 

 

On a less positive note, 25 staff, 19 D or E grade and six F grade and above, stated that clinical supervision did not help them work more effectively in their roles as registered nurses. When asked if supervision helped motivation, only 17 staff, 13 D or E grades and four F grades and above, said they felt slightly more motivated and nine staff, six D or E and three F grades and above, said their motivation had not changed. Only 25 staff, 19 D or E and six F grades and above, felt moderately confident after supervision.

 

 

Only 18 staff, eight D or E grades and 10 F grades and above, knew that the model of clinical supervision being used was the Proctor model. The other 19 staff, 14 D or E and five F grades and above, could not state what model was used.

 

 

Conclusion
Measuring the findings with little available evidence in the literature on comparative studies regarding nurses working with patients with brain injury, learning disabilities and mental illness, both adults and adolescents, was a difficult process. There was also no available literature on comparing divisions in specialty within a hospital similar to St Andrew’s. For this reason it was a unique process.

 

 

It was clear that more senior staff benefit and are satisfied with regular supervision than more junior staff. This is interesting because on average there is usually a three-to-one ratio of D or E grades to F grades and above on a typical ward. This may suggest that senior staff are receiving more supervision. However, this is probably not the case. There could be more F grades receiving clinical supervision than D or E grades in some areas and vice versa.

 

 

It seems that at the hospital, clinical supervision has little to do with the Proctor model and more to do with the people who are delivering supervision - the majority of nurses believe that their needs are being met without having a firm knowledge of the model of supervision being applied. It would be better if training were more focused on the quality of the supervisors and their experience of problem solving. As the survey shows, clinical supervision is in quite good shape, with most nurses receiving regular supervision within a limited time span.

 

 

There is a difference between F grades and above and D or E grades regarding satisfaction, which has implications for training. It could be argued that a more clinical approach rather than a managerial approach could narrow the gap. It could also be argued that more ward-based staff could have the opportunity to develop skills by supervising other clinicians and not relying on more senior staff to provide the supervision. Having said that, a large percentage of staff stated supervision does keep their skills up to date and would reflect on clinical issues rather than managerial issues. If any changes were to be made, it would probably be to the attitude and culture of the hospital rather than the training itself.

 

 

Agenda for Change, which was introduced in 2005, will have major implications for the hospital and clinical supervision. The old grading system of D, E and F will be discontinued and a new banding system - which takes into account experience, responsibility, knowledge and clinical work - will be introduced. This will give the hospital an opportunity to re-examine its philosophy and culture. This could have a positive effect on the hospital and the attitudes of staff who receive and provide clinical supervision. The hospital could also follow the lead of other hospitals and adopt a competency-based approach in line with Agenda for Change.

 

 

Clinical supervision has several benefits to the supervisee that are clearly shown in the survey. The fact that a large number of nurses receive supervision in the hospital is extremely positive and this is quite evenly balanced throughout the divisions. Having said that, the survey also shows a number of worrying discrepancies regarding who receives supervision, the time frame they receive it in and why so many nurses feel the supervision is not helping them manage their role more effectively.

 

 

- This article has been double-blind peer-reviewed.

 

 

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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