Clinical Supervision Reflection and Action Plan - Essay Example

?Clinical Supervision Reflection and Action Plan Introduction Clinical supervision has been in existence for a long period of time in the nursing field, though its use and critical application began in the early 1990’s with the support of the Nursing medical council. The practice has intensified with the concept being adopted in all fields of the medical world. Other fields have also embraced the concept of clinical supervision with a variation of the same though under a different name altogether. This paper is going to focus on the various aspects of clinical supervision. It will begin with a brief background of the concept. A definition of the concept will be provided for purposes of understanding what clinical supervision is all about. It will then look at what happens in clinical supervision including the various stages involved. It will then provide a reflection of the good things that I encountered during clinical supervision before also looking at the bad things in clinical supervision. The paper will then look at some of the key issues in clinical supervision outlining their importance and how to improve on them in the future. This will then be followed by a discussion of some of the challenges that I faced and the mechanisms that I put in place to overcome them. The paper will conclude explaining why clinical supervision is important in nursing and the difference that it makes in the entire profession. Clinical supervision There has been a longstanding assumption in the medical field that nurses and midwives for that matter “learn on the Job” but in true sense there have been very few mechanisms that are put in place to ensure this aspect happens (Bryant, 2010, p. 36 ). Clinical supervision is an aspect that was introduced way back in the early 1990’s to describe a systematic structure for professional development for nurses and midwives. This concept was seen as a means of bringing together the aspect of reflection, development, individual responsibility and accountability within a framework that offers support and promotes safe practices (Gordon, 2000, p. 27). The overall intention of introducing this concept is to be able to promote safe practice and help in identifying the wilful bad practices that are exemplified nurses at the workplace and how these can be avoided in future operations (Bryant, 2010, p. 37 ). The NMC viewed the practices by nurses as individual responsibility and therefore in 1993 they put forward a code that stated “As a professional you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions.” This showed the aspect of individual responsibility and accountability (NMC, 2008). The council later on realized the importance of clinical supervision as being essential to accountable nursing practice and therefore endorsed its adoption in every branch of nursing. However the implementation of this aspect was essentially left to the practitioners in the individualized or local situations (Jeremy & Suresh, 2007, p. 412). The council still supports the aspect of clinical supervision but believes that it is better developed at local levels in line with the local needs of the population (Bryant, 2010, p. 39 ). Clinical supervision is therefore described as “regular protected time for facilitated, in-depth reflection on clinical practice aimed to enable the supervisee to achieve, sustain and creatively develop a high quality of practice through the means of focused support and development.” (NCNM, 2008, p. 2) Brunero & Stein-Parbury (2008, p. 87) define clinical supervision as “ a process of professional support and learning in which nurses are assisted in developing their practice through regular discussion time with experienced and knowledgeable colleagues.” It is evident from this that the principle of discussion is used in clinical supervision. Discussion or reflection is used to assist the nurse’s figure out what happened in a given situation and what they were thinking about at that that time that led to an accident so that they find out how they should act if they are faced with the same situation. Reflection is essentially concerned with thinking about what you do so you can learn to do it better. The practice arena does not always turn out to be as most students would want it to be (Rolfe, 2001, p.10). This makes many graduate nurses struggle to hold onto the ideals of why they wanted to be a nurse in the first place. Reflection in nursing offers stability in such situations, something a novice can turn to help make sense of the world and re-evaluate their practice. The reflective practice helps nurses to self-correct, so that the whole aspect of continuous improvement continues to be part and parcel of the nursing practice. This brings us back to the first point of learning on the job (Rolfe, 2001, p. 10). The purpose of clinical supervision is therefore to improve the nursing practice and is thus focused on the on nurse-patient interaction. Canham & Bennet (2001, p. 63) support this by saying that the essence of clinical supervision is the support and the development of the nurse. On the other hand Butterworth & Faugier (1998, pp. 27-29) add that there are three main functions of clinical supervision and these include: Formative function which entails the educative process of developing skills; restorative function that entail the supportive help for professionals that are engaged in environments of distress and stress; and normative function attempts to develop strategies to manage the professional accountability and quality issues in nursing. What happens in clinical supervision From my experience many things happen in clinical supervision. Clinical supervision is a process that involves four stages. The first stage is to establish a working relationship where the supervisor describes his supervisory style, clarify expectations about the supervision (contract), the structure to be followed, handling emergencies, and the procedure for evaluation etc. the second stage involves assessing the supervisee’s skills and these will involve both the supervisor and the supervisee self-evaluation and forms a basis for a joint statement of the learning objectives (Borders & Brown, 2005, pp.18- 19). The assessment is done over a period of time that may involve several sessions with the supervisee. The skills assessed include performance skills and cognitive skills. The third stage is the establishment of the learning goals, objectives and the contract for supervision. The learning goals must be specific, observable and they must be broken down into realistic measurable actions steps. These goals must be prioritized depending on the assessment made in stage two (Borders & Brown, 2005, pp.18-28). The fourth stage is the selection of interventions and evaluation of progress. The supervisor in this stage must select the interventions that complement the supervisor’s preferred approach to learning and feedback styles to enhance involvement and development. They should take into account the personality of the supervisee as some of them respond best to warmth, praise and support while other would prefer a more objective critique of performance (Borders & Brown, 2005, pp.28). The above stages are generally used for all clinical supervision processes. The stages are usually incorporated in a supervision model that is usually identified by the supervisor or the institution. The models include the following: (1) competency based models that focus on the skills and learning needs of the supervisee (Alison Morton-Cooper, 2000, p. 49); (2) The treatment based model that train the use of a particular theoretical approach;(3) developmental model that focuses of different stages of development of the supervisee (CSAT, 2009, p. 4); and (4) The integrated model that use a combination of the above mentioned models (Powell, 2009, p. 8). Clinical supervision is based on a few principles that define how the process is carried out. The first principle is that the process is based on mutual respect and the creation of a safe environment that allows for reflection on practice and work-related issues (Bryant, 2010, p. 39 ). The second is adult learning as the process is based on core features of adult learning such as relating theory to practice in order to identify practical purpose for learning and to recognize past skills and experiences. This principle entails the aspect of reflection using some of the common reflective models such as the Gibbs (1998) reflective model, John’s model or Borton’s reflective model that are used especially before a session (Bryant, 2010, p. 40 ). The third principle is use of solution-focused techniques and these are used in determining the way forward in a given situation. These techniques employ constructive questioning so that an individual sees that they already have the expertise and skills to build on and provides them an opportunity to plan how to develop their strengths (Bryant, 2010, p. 40 ). The fourth principle is that of problem based learning where essentially a problem initiates the activity and a group begins to share ideas and researches evidence that is used to work with the aim of reaching a solution (Bryant, 2010, p. 40 ). The supervisor only supports and guides the process. The fifth principle is that of organized sessions where a topic is selected earlier and the supervisor and supervisee then select clinical incidents and concerns to bring to board. The session may be for live issues which call for prior preparation exploring the problem and planning a way forward. These sessions may last for one hour for individuals or two hours for groups. The last principle is that of record keeping where the supervisees keep records for their continued professional development while the supervisor keeps records of problems identified, outcomes and any further actions identified (Bryant, 2010, p. 40 ). The good things in clinical supervision There were many good things in clinical supervision. The fact that there are mentors to guide you through problems that you as a supervisee experience is a good thing. The first good thing is that the process allowed me to be creative in coming up with a solution to a problem. This was possible through the assistance of the supervisor. The process allows one to come up with a creative approach to providing treatment based on the analysis of the case or problem in question. I used to look at patients during the live case sessions and from the diagnosis I could see various options for treatment but this was not enough because as I came to find out, the observable symptoms may not be conclusive about a given disease and therefore a critical look at the situation was required before coming up with a solution to the problem. The second good thing about clinical supervision is that it teaches an individual essential social skills. Through group interaction an individual is able to learn how to relate with different people within the group. The idea was not just about relating with people but also the idea of accommodation of the varying perspectives that people have about a given issue. While discussing a given case we at times came up with different ideas about the problem and everyone had an explanation to justify their conclusions. At this point the supervisor has to come in to resolve the conflict by identifying the most critical areas of the case in question and clarifying the various perspectives that everyone had about the case. In this way I was able to understand that perceptions influence situations and lead to different analysis of cases which eventually lead to different treatments, some of which might not be appropriate. The third good thing about the whole process is that it teaches people on how to be disciplined. Being creative while coming up with treatments after case review requires discipline. One has to look at various aspects of the case without the help of the supervisor and come up with a solution based on the case in question. Adult learning requires discipline and therefore without this it is not possible to come up with conclusive remarks about a given case. The supervisor on the other hand also teaches clinical techniques and it is up to the supervisee to learn them with very little monitoring. The fourth good thing is that clinical supervision provided me with the opportunity to rehearse and practice before the actual performance. During the CS sessions, we began by looking at a case or a problem and then an analysis of the case in question. This then brought to light various things that need to be done in order to solve this problem. After this such a problem would present itself and we would be asked to take care of the patient. This was good because it gave me an opportunity to learn first and how to critically examine a case before I could make any conclusions. I would easily look at the patient and quickly diagnose the problem and be able to provide treatment. Though sometimes I failed my supervisee was always available to help me through it to reach a solution. The bad things in clinical supervision There two things that I found bad during the entire period. The first thing is the non-commitment that is characteristic of nursing practitioners. Most nurses are engaged almost all the time with very little time left to help others during clinical supervision. The culture that has been developed in most medical institutions refers to clinical supervision as a ‘nice’ concept but they do not have the time to supervise others. During the session I found out that some nurses felt that there was no sufficient time to engage fully in clinical supervision and that the entire process was not one of their priority areas of professional duty, something which is disagree with. The second bad thing is the student-supervisor relationship. In my experience I would describe the supervision sessions as characteristic of the student-teacher relationship. This is because the supervisors are only interested in disseminating knowledge and not listening to the students and taking their ideas and opinions about a given case. They also do not communicate about any matters to the students concerning various developments in their department. In my opinion clinical supervision should take the relationship of a practitioner-practitioner where there is an equal kind of relationship that exists between the supervisor and the supervisee. Though the supervisee should be there to be engaged and learn together with the supervisor, the supervisor must not treat them like students. Their suggestions, ideas and opinions must be taken into considerations and their assumptions addressed. The fourth bad thing that I experienced is lack of motivation on the part of the supervisee. Some of the supervisee would come for the sessions for formalities, just to end the day and count their attendance of the supervision. The lack of motivation stemmed also from the fact that some of them were being supervised with practitioners who did not care and were not committed to the process of supervision. This demoralized the supervisees making them even avoid the sessions because they felt that the sessions were of little help to them if any. In my view students must be encouraged by their supervisors and they should provide a conducive environment for them that is supportive so that they attend the sessions because it helps build them professionally. Key issues in clinical supervision There are various keys issues in clinical supervision. The first issue is that of legal and ethical concerns that come about during the process of supervision. Studies show that many clinical supervisors possess very little knowledge of the legal and ethical risks that come along with clinical supervision. Increased attention has thus ben paid to supervisor liability and malpractice. The major issue that has been of concern is that of vicarious liability that refers to the legal doctrine which holds that “one who occupies a position of authority or direct control over another (such as a supervisor and supervisee, employer and employee) can be held legally liable for the damages of another suffered as a result of the negligence of the subordinates.” The idea here is to ensure that the supervisor is careful enough during the clinical supervision sessions so as to ensure no incidents emerge as a result of negligence of the supervisee which may be fatal or put others at risk. Therefore the supervisor is held legally and ethically responsible for all the professional activities of the supervisee as well as his own actions as a supervisor. My experience as a supervisor taught me that being busy and leaving the supervisee to make decisions on their own is not professional and cannot be used a s a defence in the court of law or to the board. All actions should be taken seriously. If the supervisee has made an error it is good to make corrections earlier in order to avert any danger that the action might bring. In order to avoid these problems in future I decided to take full charge of the sessions knowing that I was legally and ethically responsible for the actions. I also must ensure that I have knowledge on each and every case that the supervisee is working on to endure safety. Another key aspect of the process is to learn communication skills. These include both written and spoken so as to be able to issue instructions appropriately and in order that you may understand each other during the process. Here it is important that the supervisor works on improving his communication skills so that they are effective. These skills also come in handy during interpersonal conflicts that present themselves during the process. Good communications skills will prove helpful in averting interpersonal problems that may arise. The third key point has to do with decision making such that during the process many decisions have to be made concerning cases. The supervisor and the supervisee may have different perspectives on the issue at hand especially in group supervision. It is important that a decision is made collectively on a given case after careful research has been done on the issue. Collective decision making is advantageous because of the fact that the group is responsible for the decision and that an agreement reached by a number of people after careful analysis of literature is considered credible. In future I thought of engaging colleagues in cases that I am not certain if I can handle so that we come up with a decision as a team which would be helpful to me. Challenges and how they were overcome I faced various challenges during my time both as a supervisor and a supervisee. The first challenge is that of supervisory enabling. This is where the supervisor does everything for the supervisee allowing them only to watch as they go on with the work or the supervisor makes excuses for why the supervisee has not performed at a professional level. A good example of supervisory enabling is when the supervisor fails to address the dysfunctional behaviour of the supervisee allowing the supervisee to continue performing incompetently. To avoid this, supervisors must ensure that they hold the supervisee responsible for their actions and guide them through the process correcting them and helping them become better professionals in the field. On my side I tried to engage the supervisor requiring that they correct my mistakes if any and guide me through the correct process during the supervisory sessions. The second challenge that I faced is that of building effective relationships with the supervisors. I came to realize that people are different and the first step to a successful clinical supervision session is the choice of the supervisor (Edwards, et al., 2005, p. 410). A good supervisor is one who is knowledgeable, provides a positive learning environment by challenging the supervisee knowledge, skills, attitudes and behaviours in a positive helpful manner for the purpose of bringing out blind spots and ineffective clinical behaviour for the good of the supervisee and patients. I found some supervisors arrogant, non-committed and often neglected the supervisees to handle responsibilities on their own. To solve this I got to know a few practitioners at the institution before selecting one that I thought was good enough. I strive to build a positive relationship that helped me through the entire session. Other scholars agree with this fact and many say that for clinical supervision to be worthwhile for all parties involved, a healthy professional relationship is necessary (Russell-chapin & Chapin, 2010, pp. 12-15: Cutcliffe, Butterworth, & Proctor, 2001, pp. 116-118:Cerinus, 2005, p. 34). The third challenge was that of boundary crossing and dual relationship issues. A dual relationship occurs when a supervisor has a primary professional role with a supervisee and at an earlier time, simultaneously or later engages in another relationship with the supervisee that transcends the professional relationship. This becomes a challenge because the supervision is most of the time characterized by unequal power and therefore the supervisor may abuse or exploit the supervisee (Lynch, Hancox, & Lappell, 2008, p. 170). To overcome this I tried first of all to pick a supervisor of the same gender with me and to come up with a contract showing the boundaries of the relationship. Studies show that the most common basis for legal action against counsellors (20% of claims) and the most frequently heard complaint by certification boards against counsellors (35%) is some form of boundary violation or sexual impropriety (Broderick & Clark, 2009, p. 14). This proves makes it a big problem that must be addressed through codes of ethics and contracts before supervision begins. The fourth challenge was lack of confidence during the supervision sessions. Lack of confidence was evident in the way the supervisees responded to questions they were being asked about a given case. Though they showed a grasp of knowledge, they could not express themselves well because of the fear of saying something that was not correct. They also feared because some of the supervisors reprimanded them for conclusions they made about cases under study. Lack of confidence was also evident from the little knowledge and experience they had in medicine and some of the cases under study were their first live cases to handle and therefore they did not know what to do. In order to solve this, I exposed my peers to a case and then told them to conduct further research and analysis about the case. In this way they came back with knowledge and this gave them confidence to speak about what they had researched. I also ensured a warm environment that encouraged them to speak freely and thus reducing some of their fears of making wrong conclusions. The difference that clinical supervision makes in Nursing Clinical supervision is an essential component of nursing and contributes a great deal to the profession in so many ways. The NMC supports this by saying that clinical supervision enables registered nurses to: (1) identify solutions to problems; (2) Increase understanding of professional issues; (3) improve standards of patient care; (4) Further develop their skills and knowledge; and (5) enhance their understanding of their own practice (NMC, 2008). Clinical supervision makes a huge difference in the nursing profession. It is essentially based on the cognitive process of reflection identified earlier on. This process allows practitioners to think back on clinical experiences in order to recount them and get a deeper understanding of the incident and in so doing identify areas that require improvement (Price, 2004, p. 46). Reflection is very important to professional growth in a practice based field such as nursing. That is nursing is deeply rooted in experience and learning through experience is important to the practice of professional nursing and this makes clinical supervision a worthwhile exercise (Brunero & Stein-Parbury, 2008, p. 87). Clinical supervision gives nurses a chance to discuss patient care in a safe, supportive environment. As the nurses engage in the whole process they are able to provide feedback and input to their colleagues in a bid to increase their knowledge and understanding of clinical issues (Brunero & Stein-Parbury, 2008, p. 87). In this sense the process of clinical supervision is designed to serve a peer-educative function despite the people involved in the process whether they are students or practitioners. Clinical supervision provides the opportunity to discuss general issues in relation to patient care and in so doing also opens an avenue to develop consistent approaches towards patients. It therefore enables nurses to improve the quality of patient care for specific patients and generally in relation to maintaining standards of care (Brunero & Stein-Parbury, 2008, p. 87). There are many problems that nurses face in their day to day endeavour to take care of patients. These activities are very strenuous and contribute to emotional distress and stress (Price, 2004, p.46). It is through clinical supervision that nurses are able to provide each other with a supportive environment necessary to eliminate the stress and keep them healthy. Through the process of discussion in a conducive environment, they realize that they are not an isolated case in their feelings and perceptions and in so doing get reassurance and validation. This makes the clinical supervision important for all nurses (Brunero & Stein-Parbury, 2008, p. 87). Clinical supervision leads to the professional development of both the supervisee and the supervisor, and the development of the nursing profession. The supervisee is able to learn new ideas and approaches to deal with clinical problems while on the other hand the supervisor through incorporating the ideas of the supervisee and his/her opinions about a clinical case gains a new insight into a problem and thus is able to build his knowledge and develop into a better professional (Brunero & Stein-Parbury, 2008, p. 87). This in turn builds the nursing profession. Conclusion In conclusion, clinical supervision is a developed concept in the nursing world. From the discussion it is evident that clinical supervision is appreciated for the various contributions that it makes to the nursing field. It is a process bound with principles that must be applied for it to work effectively. In the sessions I realized both good aspects and some bad aspects of it at the same time. The good aspects outweighed the negatives and this shows that it is something good that can continue to be implemented across the profession. In the process of supervision it has been seen that it is important that a supervisor understands various key issues such as legal and ethical concerns that affect both the supervisor and the supervisee. Improved communication and collective decision making are also some aspects that must be put into consideration by supervisors to ensure success of the sessions. All concepts must have challenges when they are developed. Clinical supervision has challenges such as supervisor enabling, ineffective relationships and dual relationships. All these must be addressed in order if clinical supervision has to bear some fruits. In the process I came up with means of combating these challenges that helped me realize the good side of clinical supervision. Clinical supervision therefore is very important in the nursing profession and provides peer support and stress relief for nurses, promotes professional accountability and also promotes skill and knowledge development (Bryant, 2010, p. 38 ). All these makes clinical supervision an important aspect that makes a huge difference in the nursing field. References Alison Morton-Cooper, A. P. (2000). Mentoring, preceptorship and clinical supervision: a guide to profesional roles in clinical practice. New York: John Wiley & Sons. Borders, L. D., & Brown, L. L. (2005). The New handbook of counselling supervision. Mahwah, NJ: Routledge Publishers. Broderick, E., & Clark, H. W. (2009). Clinical Supervision and Professional Development of the Substance Abuse Counselor. Retrieved February 19, 2012, from U.S Department of Health and Human Services: http://kap.samhsa.gov/products/manuals/tips/pdf/TIP52.pdf Brunero, S., & Stein-Parbury, J. (2008). The effectiveness of clinical supervision in nursing: an evidence based literature review. Australian Journal of Advanced Nursing (Online), 25(3): 86-94. Bryant, L. (2010 ). Clinical Supervision. Practice Nurse, 39(12): 36-41. Butterworth, T., & Faugier, J. (1998). Clinical Supervision and mentorship in nursing. Cheltenham, UK: Nelson Thornes. Canham, J., & Bennet, J. (2001). Mentorship in community nursing: challenges and opportunities. New York: John Wiley & Sons. Cerinus, M. (2005). The role of relationships in effective clinical supervision. Nursing Times, 101(14): 34. CSAT. (2009). Clinical Supervision and Professional Development of the Substance Abuse Counselor. Rockville: Substance Abuse and Mental Health Services Administration. Cutcliffe, J. R., Butterworth, T., & Proctor, B. (2001). Fundamental themes in cinical supervision. New York: Routledge Publishers. Edwards, D., Cooper, L., Burnard, P., Hanningan, B., Adams, J., Fothergill, A., et al. (2005). Factors influencing the effectiveness of Clinical supervision. Journal of Psychiatric and mental health nursing, 12(4): 405-414. Gordon, N. (2000). Clinical Supervision. Nursing Standard, 14(16): 27- 32. Jeremy, M., & Suresh, P. (2007). Embracing Clinical Supervision. British Journal of General Practice, 57(538): 412. Lynch, L., Hancox, K., & Lappell, B. (2008). CLinical supervision for nurses. New York: John Wiley & Sons Publishers. NCNM. (2008). Clinical Supervision: A structured approach to Best Practice. Retrieved February 18, 2012, from National Council for the Professional Development of Nursing and Midwifery: http://www.ncnm.ie/items/1299/85/3167984576%5CClinical%20Supervision%20Disc%20paper%202008.pdf NMC. (2008). Clinical suervision for registered nurses. Retrieved February 19, 2012, from Nursing and Midwifery Council: http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Clinical-supervision-for-registered-nurses/ Powell, D. J. (2009). Clinical supervision and professional development of the substance abuse counselor. Washington DC: DIANE publishing. Price, A. (2004). Encouraging reflection and critical thinking in practice. Nursing Standard, 18 (48): 46-52. Rolfe, G. (2001). Critical reflection for Nursing and the Helper Professions: A users' Guide. Basingstoke: Palgrave. Russell-chapin, L. A., & Chapin, T. (2010). Clinical Supervision: Theory and Practice. New York: Cengage Learning. APPENDIX Clinical supervision action plan Development need Action Time to complete Communication skills Effective supervision is based on good communication skills which I found underdeveloped during my supervision. I plan to engage read literature on how to develop good interpersonal skills and good social skills that are essential for a good supervisor. I also plan to develop my listening skills so that I am able to listen to my supervisees well and be able to give them direction and assistance whenever they are in problems. I also plan to develop my writing skills so that I am able to make records of the sessions and offer advice to supervisees at any time even after the sessions through emails. Continuous Professional competency I found myself lacking in essential skills for a nursing professional and therefore I was not ready to become a supervisor. I am working on completing my studies, going for extra placements and volunteer to work in hospitals so that I gain the professional competency that will help me be a good supervisor. I will also consult other practitioners in the field who are willing to mentor me in this way I will advance my skills and knowledge that will make me a better supervisor Continuous Critical thinking and analysis skills Supervisors need to look beyond the obvious and go deep in a given case to identify causes and underlying issues to a problem. I realized that I looked at cases less critically and therefore provided obvious diagnosis that sometimes were misleading. I plan to take time on cases to get a clear understanding of problem. I also plan to come up with a variety of solutions to cases and eliminate them based on evidence in order to reach at the most viable solution. I also plan to make sure that I gather enough information about a case before beginning my analysis. Continuous Knowledge of ethical and legal issues Supervisors are usually faced with so many issues during supervision. These issues raise legal and ethical concerns for these practitioners. Issues such as vicarious liability and boundary crossing are very critical issues that must be addressed. I plan to identify many of these issues seek legal advice on how to solve them. Ethical issues will require that I go through the ethical code of conduct and know how to handle each and every case. In issues of boundary crossing, I will make sure that a contract is established at the beginning of the session that sets out the various responsibilities and my boundaries as a supervisor. 1 year Best practices All professions are built on best practices within the discipline. Just like any other discipline nursing is based on best practices that have worked elsewhere though the cases and problems keep on changing. The best practices provide a starting point to ensure quality of treatment. I plan to read widely on literature available in nursing identifying best practices that I can incorporate into my supervision. I will also consult other practitioners to find out what they have been doing to find out what best practices they know that will be beneficial to my supervision sessions. continuous Read More