Applying theory to practice through clinical supervision. This is an extended version of the article published in Nursing Times; 104: 30, 30-31.
Frankel, A. (2008)
Andrew Frankel, MSc, BA, RN, MH, DipN, PGCMS, is hospital director, Churchill Gisburn Clinic, Lancashire.
Effective mentorship is critical in delivering high quality care, ensuring patient safety, and facilitating positive development of staff. Nurses must use mentorship skills in providing workplace, informal and formal one to one supervision to support workers in order to facilitate their professional maturity. This will enable support workers to apply theory to practice and encouraging them to test new skills in a safe and supportive environment (Miller et al, 2000). A successful mentor will seek to develop staff whilst working alongside team members in a mentoring and coaching role.
The mentor needs to provide an appropriate learning environment, relevant resources, and the desirable level of structured support and guidance to promote professional growth and development. The individual support worker must interact with the mentor in a manner which suggests they are prepared to learn. They must demonstrate personal motivation and an attitude that is open to acquiring new knowledge. Workplace learning, through structured mentorship, coaching and supervision needs to be recognised by organisations as an important future strategy in bridging the theory to practice gap, motivating support workers, and promoting the application of knowledge to practice (Dewar and Walker, 1999)
The existing training model for healthcare support workers in the organisation is based on traditional teaching strategies using a range of presentation skills. It has significant limitations because of its passive and didactic teaching methods. Training is facilitated in group learning environments and there is little consideration given to the dynamics of the group, including; range of intellectual capability, previous experience, personality types, or individual learning styles. The current training philosophy is crudely based on supply and demand, meeting targets and ensuring compliance with legal frameworks for the provision of mandatory training programmes. Low emphasis is placed on work-based practice supervision and mentorship and there is limited follow-up from training courses to see whether knowledge is being applied to practice.
Santos and Stuart (2003) advocate that even though organisations invest millions of pounds in training programmes they often devote little attention to evaluating the effectiveness of training. There has been a recent cultural shift in continuous professional development away from classroom based teaching to interactive workplace learning through good mentorship.
Research pertaining to effective training for support workers has identified a need for a problem-centred, work-based learning programme incorporating a high level of clinical supervision and mentorship from qualified professionals. Terminology frequently used to describe a mentor includes teacher, supporter, coach, facilitator, assessor, role model and supervisor.
Mentorship is not dissimilar to leadership, which Adaire (2002) defines as ‘the art of influencing people to follow a certain course of action; the art of controlling them, directing them and getting the best out of them’. Effective leaders are required to use problem-solving processes; communicate well, demonstrate leadership fairness, competence, and creativity. In comparison mentors should be; dynamic, passionate, have a motivational influence on other people, be solution focussed, and seek to inspire others.
By demonstrating an effective mentorship style the nurse will be in a powerful position to influence the successful development of staff, ensuring that professional standards are maintained and enabling the growth of competent practitioners.
Training should not be confined to the classroom and should include practical as well as theoretical elements; there should be good supervision which promotes accountability of the support worker and also provides feedback in a supportive environment. Supervision ensures the competence of the support worker and provides pastoral support (Naknikian et al, 2002; Nancarrow and Mackey, 2005).
A study conducted by Coffey (2004) found that responses from support workers to questions regarding the type of training they preferred displayed an overwhelming interest in an ‘on the job’ model of training. In considering a new practice model we should examine the usefulness of work based mentorship and supervision as part of training strategies where the one to one mentorship relationship is the most important element in clinical instruction.
Much of the available research pertains to the mentorship of qualified professionals such as nurses, social workers, and medical students. There appear to be very few studies which relate directly to the application of theory to practice through supervised practice and mentorship of unqualified support workers.
Aim and method
This study aims to demonstrate that professional development is a dynamic process and can be described as a partnership between the support worker and the mentor.
A self-selecting sample of support workers (n=40) was identified from within the organisation to participate in this study and they were asked to complete questionnaires. From this initial group of participants, a stratified sample was selected (n=10) to take part in structured interviews. In addition focus group discussions (n=2) were facilitated with senior managers and directors of the organisation.
All participants had worked for the organisation for longer than six months. This ensured that participants had experienced the training programmes and existing support systems, and could be regarded as a representative sample of all support workers within the organisation.
This study utilises a multi-method approach combining qualitative and quantitative methods of data collection. A questionnaire was developed following an examination of previous studies that elicited themes that had been useful in providing data. The questionnaire encourages the participant to consider issues of applying theory into practice through mentorship and supervision and whether or not this is currently being promoted within the organisation.
Results and discussion
A 100% response rate was recorded for this study. More females were sampled than males (F= 27, M=13) which was representative of gender divide in the organisation and the majority (37; 92.5%) of participants had been with the organisation for longer than 12 months.
Some data gained from support worker interviews was not as good as expected. This was predominantly due to the individual differences in response style, confidence and verbal facility of the person being interviewed. This determined how much information they contributed during the interview.
In a climate where the support worker role is expanding it is important that they have underpinning knowledge for their practice. Support workers have become an important part of the health and social care sector and are accepting more responsibility for tasks previously undertaken by nurses (McLaughlin et al, 2000). This increased responsibility must be coupled with application of knowledge to ensure that their practice is safe and competent.
Support workers who are unable to apply the knowledge they have acquired through training could be unsafe. The most effective method of work place application of learning is through a structured and disciplined supervision and mentorship programme as learning is an on-going continual process.
The results of this study demonstrate that this level of supervision is not occurring across the organisation (Table 1). A combination of lack of confidence, inexperience, lack of supervision training, and an absence of depth of their own professional knowledge lead to many nurses being poorly equipped to deliver effective clinical supervision.
Developing the nurse’s ability to fulfil their role as a competent mentor became a core theme in this study, with 47.5% of respondents suggesting that they did not get effective coaching and guidance from nurses, and only 32.5% trusted the nurses enough to give them the right supervision and support in applying learning to practice. Some interviewees suggested there was no consistency of information that nurses gave them, with one saying ‘if you go to three nurses with the same question you will get three different answers’.
The interviewees indicated that they got frustrated and confused by this inconsistency and looked to fellow support workers for advice instead. It appears that support workers have most confidence in their peers.
Disappointing results were recorded for all areas pertaining to nurses in a supervisory/mentorship role. Only 16 (40%) agreed that their supervisor regularly discussed their training and development needs with them. One of the most concerning results is that only 14 (35%) of support workers agreed that their supervisor worked alongside them to demonstrate how they can apply their learning to practice, and only 21 (52.5%) recognised that their supervisor coached and guided them effectively.
Support workers did not have frequent contact with their supervisors and it was evident that the supervision process was not being implemented effectively. Supervision occurred every eight weeks but each supervision session was viewed in isolation from the previous session. Nurses generally appear to have viewed supervision as a ‘task’ that needed to be completed rather than an important development process; these attitudes provided little benefit to the support worker.
The formal supervision session should be an evaluation at the end of an eight-week mentorship and a coaching process based on goals which were set in the previous supervision. The formal supervision session should then be used to set the goals for the next eight weeks of coaching and mentorship (Fig 1). It is this mentorship/coaching link which is currently missing and has negative implications on the support worker’s ability to integrate theory and practice.
Work-based learning through mentorship promotes learning that is practice driven. This encourages the practitioner to learn how to apply theoretical knowledge usefully in their practice; encourages the practitioner to consider aspects of their practice which could be changed and guides them through the process of implementing change. Work-based learning also provides an opportunity for the practitioner to develop reflective and other transferable learning skills.
It was encouraging that all 40 of the participants stated that they would like to be given the opportunity to use the knowledge and skills they have learned as a result of the training. This indicates a strong commitment from the support workers to implementing theory into practice. The organisation should support this level of motivation by ensuring that the appropriate mentorship systems are in place to sustain their commitment.
Interviews with senior managers revealed that there were no formal written guidelines to assist nurses in facilitating support workers’ development through mentorship and coaching or to assist support workers to identify how they might be supported. None of the nursing staff had received any formal training from the organisation to prepare them for their role as a mentor or supervisor. However, if support workers are to do more than simply remember the training they have attended then nurses must be able to challenge them to think critically and also to:
- Make observations and inferences;
- Analyse situations;
- Organise and interpret information;
- Weigh up the accuracy of diverse points of view.
Such practice should form the cornerstone of mentorship sessions. Support workers need to spend time reflecting on themselves and feedback on their performance from other people. These roles can be critical in encouraging support workers to try out new workplace behaviours and learn from their experiences.
Support workers look to other peers for guidance and support in implementing knowledge because they do not get appropriate coaching from nurses. This is potentially problematic as the accuracy of information or the level of competence of the peers who are providing information might be questionable and could encourage bad practice.
The support workers perceive their role as being ‘the ones who actually do the hands-on practice of the job’. It is concerning that they are doing this without the appropriate level of mentorship and supervision from nurses.
Of the support workers who participated in the survey, 27 (67.5%) agreed that it is important that part of supervision time should be spent encouraging them to reflect on their learning using a recognised reflective practice model. Nine respondents answered ‘don’t know’ (22.5%), which could mean on this occasion that they did not understand the question, having had no previous experience of reflective practice.
Page and Meerabeau (2000) suggest that if the reflectors, for a variety of reasons, perceive themselves to be in a powerless position to orchestrate changes or suffer from what might be termed professional apathy, learning and practice are unlikely to be advanced. This might be true for the sample of support workers in this study as only 19 (47.5%) agreed that they find it easy to apply the things they learn in training to their practice as a support worker. This could suggest that they may not be given either the appropriate opportunities to apply learning or receive the right level of support. This can be compared to the 100% of support workers who state they would like to be given the opportunity to use their knowledge and skills that they have learned as a result of the training.
The results suggest that the support workers are eager to apply knowledge to practice but are lacking the important leadership support from nurses that should be provided through structured supervision and mentorship. The effective mentor guides the support worker through a process of reflection on everyday workplace experiences. It is through this process that support workers identify with what constitutes good practice. They are then able to apply their learning in the workplace, improving quality of care and develop into competent practitioners.
It is fundamentally important to establish the mentorship relationship and begin to encourage coaching activity through qualified nurses. The primary relationship in any mentorship activity is between the coach and the individual, but this is not the only important relationship. Other key stakeholders including ward managers through to hospital directors are interested in methods of improving performance and should be directly and indirectly involved in mentorship of more junior staff.
Nurses have suggested during informal discussions that demands on their time in running a busy shift do not allow them to provide supervision and structured mentorship to support workers. An alternative option for the organisation might be to consider providing supernumerary time for the completion of supervision or to appoint a clinical teacher to deliver a mentorship/coaching programme. The clinical teacher would be clinically as well as educationally credible and based on the ward to provide knowledge to nurses in addition to providing mentorship and supervision to support workers.
This option was discussed in the focus group which concluded that the ward manager should be responsible for developing nurses and ensuring that effective mentorship systems are in place. The suggestion made for the appointment of a clinical teacher was rejected. Instead, the focus group suggested that a greater synthesis was required between the variables; appraisal (bi-annually), supervision (eight-weekly), and mentorship (daily) with clear line management and goal setting responsibility for each element. A model was developed by the focus group and attempts to demonstrate the interrelationship between formal supervision and mentorship following appraisal (Fig 2).
Using reflection has been highlighted in literature as an important and powerful tool when attempting to integrate theory with practice. Reflective practice provides the support worker with an opportunity to review their decisions and evaluate their learning in order to learn from lessons in the past and positively influence practice in the future. Watson et al (2002) hypothesise that experiential learning is an essential part of learning to reflect on and analyse one’s own practice. In order for support workers to be able to successfully implement theory into practice they must be able to reflect critically on their own practice and the implications of their interventions.
Providing the appropriate level of learning and supervision to the support workers in the organisation can be problematic. Mentors are unlikely to be able to provide the level of mentorship and supervision required to have a significant impact on learning without increasing their workload. In a study by Coffey (2004) it is reported that while support workers welcomed involvement in training and assessing from qualified nurses, 62% of nurse respondents in the study were disinterested in being personally involved in training. Reasons given were mainly ‘no time’ and complaints of an ‘already heavy workload’. Some nurses also felt that they were ‘not qualified to teach’. The learning environment has clearly has an impact in either encouraging or impeding a positive learning experience for the support worker. Important within this is the willingness and experience of workplace mentors and supervisors.
There are several ways in which the successful application of theory into practice could be assessed and are directly beneficial to qualified nurses. These include:
- A more empowered and motivated workforce;
- Decrease in incidents / accidents because staff are applying good theory-based practice;
- Performance standards will improve;
- Increased staff retention,
- Decreased sickness levels.
Where mentorship has been successful it can lead to a more skilled and competent workforce which in turn improve clinical outcomes such as; reducing clinical risk, providing more effective intervention and increasing quality of care for clients (Block et, 2005).
There is a clear correlation between effective mentorship and motivation. Support workers who experience success instead of failure will have a more positive self-concept, more trust in their ability; they will assume more responsibility for their results, and will display higher levels of engagement, effort and persistence. This will lead to a more positive attitude toward learning and subsequently to the application of theory to practice.
In this study only 28 (70%) support workers felt that they were encouraged to apply the things they learn to their working practice. A stimulus-response perspective on this would suggest that rewards shape behaviour and behaviour that is reinforced is likely to occur again. It is therefore fundamentally important to reinforce positive learning. Results of this survey suggest that staff often feel that they are not being encouraged or rewarded for their learning and therefore have decreased motivation to learn or the apply learning to practice. Mentors must be astute in reinforcing support workers attempts to applying knowledge to practice. Sustained learning happens only when individuals are motivated to learn, know why they are learning and are supported by others, including their mentor/supervisor.
If the professional development programme is not meeting their learning needs staff will be unsure of their role or what is expected of them. In the long term lack of effective learning may lead to decreased motivation because of a lack of confidence in their ability to perform their role effectively, increased sickness rates and high turnover of staff which leads to a lack of continuity of care and destabilises the therapeutic environment.
The support worker’s role extends beyond merely supporting qualified professional colleagues. Support workers take on roles including; key worker responsibilities, care planning, care review and personal care, and they are often required to supervise people who are experiencing serious health difficulties. A skilled and competent workforce which has the ability to bridge the theory/practice gap is therefore fundamental to patient safety and wellbeing. With better mentorship and supervision the support worker will be encouraged to implement their learning into their practice. This will increase their self-confidence making them more motivated toward their role.
Adaire, J. (2002) Effective Strategic Leadership. London: Pan MacMillan.
Block, L. et al (2003) The value of mentorship within nursing organisations. Nursing Forum; 40: 4, 134-140.
Dewar, B., Walker, E. (1999) Experiential learning: issues for supervision. Journal of Advanced Nursing; 36: 6, 1459-1467.
Coffey, A. (2004) Perceptions of training for care attendants employed in the care of older people. Journal of Nursing Management; 12: 5, 322-328.
McLaughlin, F. et al (2000) Perceptions of registered nurses working with assistive personnel in the United Kingdom and the United States. International Journal of Nursing Practice; 6: 46-57.
Naknikian, E. et al (2002) Nursing assistant training and education: what’s missing. Nursing Homes; Long Term Care Management Magazine; 51:6, 48-51.
Nancarrow, S., Mackey, H. (2005) The introduction and evaluation of an occupational therapy assistant practitioner. Australian Occupational Therapy Journal; 52: 293-301.
Santos, A., Stuart, M. (2003) Employee perceptions and their influence on training effectiveness. Human Resource Management Journal; 13: 1, 27-45.
Watson, F. et al (2002) Integrating Theory into Practice in Social Work Education. London: Jessica Kingsley Publishers.