Critically analyse a supervision session either drawn from the session or your own experience or from your simulated session and use relevant, up to date theory to support and oppose your positions. Reflect on 3 clinical key issues occurred during the supervision event.
Introduction:
In this essay, I will critically analyse and reflect on my supervision session and scrutinise on three key issues that have arisen during my supervision session. The issues I will address are communication, time management and a lack of insight. As a Practice Educator and Mentorship Facilitator, I take on the responsibilities of students, ensuring that their practical education is up to a high standard and that their targets are met. As a Practice educator, there are several issues that arise on a regular basis and need to be addressed, managed and organised to overcome obstacles in the area of supervision. This essay will predominantly focus on the issues risen by supervision and how, as a supervisor, to deal with such issues.
Supervision is a process that provides the opportunity for reflective practice. It is a confidential space in which to step back or take a pause from practice to reflect upon work-related issues and the impact that they may be having on the individual, either personally or professionally.
Procter[i] described the functions of professional supervision as formative (professional development), normative (administrative) and restorative (supportive).
Clinical Supervision specifically, has been described as “a joint endeavour”[ii] in which a practitioner under the guidance of a supervisor, attends to their clients, themselves as part of their client-practitioner relationships to improve the quality of their work, transforms their client relationships, unceasingly “develop themselves, their practice and the wider profession”.[iii] This implies that in order for effective supervision, the supervisor and practitioner must work hand-in-hand to achieve the target of self-development and client satisfaction with further development to the greater cause being the profession. Scholars have further defined it as the ‘provision of guidance and feedback on matters of personal, professional and educational development in the context of a trainee’s experience of providing safe and appropriate patient care’.[iv] Clinical supervision has also been described as “a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations”[v]. According to Hirons and Velleman (1993), ‘the factors contributing to effective supervision’ Clinical Psychology Forums are the direct guidance on clinical work, joint problem solving, reassurance, theory-practice linking and soliciting ideas from trainee[vi]. The common principle regarding the aspect of clinical supervision, is the idea of joint endeavor, working together with a supervisor. Also, there must be, effective client service and personal development along with the development of the profession.
Regarding the aspect of reflection, I was able to look from the student aspect as well as the mentoring aspect. Reflection is pivotal to clinical supervision. I used Gibb’s model[vii] of reflection to assess me in the process of supervision. I used Maslow’s Hierarchy of needs to see where we stood as individuals. In order to convey the message, I spoke to the individuals (Learner, trainer, and the team members) individually and collectively.
Clinical supervision is a focused, structured and educational session where the student is provided with all tools to succeed individually. It is collaborative in nature, where the supervisor and supervisee work together in order to achieve targets and ensure that the supervisee is equipped with skills for the workforce. The supervision sessions are fundamentally influenced by core beliefs, with an effective way of setting achievable targets based on the strengths of both parties. Whilst doing so, issues such as current fears or concerns, areas of development, recognition of learning style, level of support required, the expectation of a relationship, the experience is taken into consideration to provide the optimal supervision session for the individual student.
Ground rules and responsibilities are clearly defined, with a contract of commitment that includes a commitment to confidentiality, open and honest, sharing best practice, seeking research for evidence-based practice, facilitating new learning opportunities, and relevance to clinical practice.
Clinical supervision sessions are to be structured and managed with defined aims and objectives. The structure should include a process, an evaluation system and the outcomes to measure success. As the supervisor, I should discuss the frequency of supervision sessions, expectations regarding the relationship, availability and willingness to be contacted as assistance are required, and advice on a day to day basis. I also need to identify any learning barriers such as language, culture, physical impairment, past experiences, motivation and personality traits in order to ensure that the student can effectively produce a high standard of work.
As to feedback, I am required to make sure that several aspects are covered as follows: one thing at a time, be balanced – focus on behaviours to keep as well as things to change, focus on behaviours (not the person), be specific – give examples of what you experienced, describe the impact of their actions/behaviour, provide alternatives – share ideas, ask for their view – listen and limit the amount of feedback.
Rules for giving negative feedback: Don’t avoid it, avoid historical references – here and now vs thee and then, never in public, balance – behaviours to keep as well as change, avoid undue emotion, avoid insincere praise – undermines trust, do not reject person ( you never get it right) – maintain self-esteem, avoid premature judgement, avoid buck-passing – assume full responsibility for your area of accountability, avoid threats – if behaviour merits discipline takes action promptly, and give a path forward, provide alternatives – end positively.
Practical Analysis:
A final year nursing student on the pre-management placement needed to be competent in the areas of communication, time management, delegation, management of a group of patients, record keeping. Previous placement staffs have identified that the student requires more support in 3 areas. Had actions made for the improvement of the student’s performance in the next clinical placement.
The student came to the final management placement with the action plan, which required completion along with the new management skill. The student is aware of the above following achievement and continues to learn and strive for accomplishment. The link lecturer and the education team were involved in the assessment of the student performance. Again, the action plan continued for this placement too. Regular visits and supports were given to the student. The holistic approach was given to the student. One of the key issues was Communication.
According to the dictionary, the definition of communication was the imparting or exchanging of information by speaking, writing or using some other medium. Communication is a very important aspect in providing high-quality patient care. NMC code of conduct states that to communicate clearly you must: “use terms that people in your care, colleagues and the public can understand. [And must] take reasonable steps to meet people’s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people’s needs. [Must also] use a range of verbal and non-verbal communication methods, and consider cultural sensitivities, to better understand and respond to people’s personal and health needs check people’s understanding from time to time to keep misunderstanding or mistakes to a minimum, and be able to communicate clearly and effectively in English”[viii]. The student should be able to communicate within the team as well as outside the team. Communication is considered an “invaluable skill”[ix] needed for nurses to advocate for and attain optimal patient outcomes. The article ‘Determination of Problem- Solving and Communication Skills of Nursing/ Midwifery Students’ states that “problem-solving process, which requires creative thinking, is at the heart of nursing practices”[x]. And it’s been highlighted that students with high communications also has had a high level of problem-solving skills. It can be said that problem-solving skills and communication skills are skills that go hand in hand with each other. The greater the level of communication of the student, the greater is their ability in problem-solving. The study also identified that external factors such as the student’s demographic characteristics, experience as a companion in the hospital, difficulty in relationships with patient and negative experiences with patient or patient’s relative didn’t affect the problem-solving ability and in return didn’t affect their communication skills. However, the researchers observed that the lack of student participation in social activities and their difficulty in interpersonal communication in daily life affected their problem-solving skills and communication skills. Also, the experience of hospitalization and a negative impact on their communication skills. This study concludes that student participation in more social activity and training in nursing education will improve communication skills along with problem-solving skills. The ‘curricula should be restructured in a manner to further improve communication skills of students’[xi]. In supervision sessions, I have noticed bad communication among nursing students about the day’s work. On a regular basis, I ask the student to present the care of patient they are responsible for, where it is evident that the students lack communication skills to express the patient care provided and the information of the patient in order of name, age, diagnosis, medication history etc. In the day to day practices of the student, communication is vital as it would help the treatment of patients if any abnormalities are to arise. During my supervision, I also noticed that students lacked the problem-solving ability during an emergency crisis. The final year student, under my supervision, was assigned a patient who became unresponsive. The student who was assigned the care of the patient lacked knowledge of what to do in the situation. The student also failed to communicate the situation to senior staff or conduct the emergency protocol. From my practical experience of conduction supervision, it can be said that there is a lack of communication skills among nursing students but the reason for it is open to question. Following the incident, the debrief session was conducted. Time for reflection using Gibb’s cycle, we were able to identify the factor behind the incident. The ill health of the student has an effect on the decision making and communication skills.
The issue with communication is further complicated among genders. The article ‘Men are from Mars’ highlights several issues in terms of theoretical issues with communication among different gender in the education of nursing (especially among men). The research highlights the difficulties that male nurses face as they try and assimilate themselves in a profession dominated by the opposite sex. It has me observed that men, in their communication, do so in a manner that is ‘to the point’ whereas woman communicated in a way of negotiation and centred on maintaining solidarity. It can also be said that male nursing students were often sensitive to being isolated due to their method of communication and the possibility of it being misinterpreted by peers of the opposite gender for being forthright and to the point. Male students were often perplexed how the female students communicated to and about each other, especially their cattiness and bitchiness. The men, on the other hand, were open and honest regarding their communication with each other and it was found that there was no misinterpretation because men knew where they stood with each other. During my supervision I have noted, that male students are more reserved in conversation and when they do, they are straightforward regardless of the possible misrepresentation. In one of the supervisions, when students were inquired regarding the procedure observation, the male student answered precisely to the point. On the other hand, the female student elaborated on the answer. It can be said that any information passed will be remembered by male students, but with female student domination, the information may seem wrong.
Communication, especially among student nurses and junior doctors, seem to be strained to some extent because the student forgets that the junior doctors are in a similar position to them and that they need to conjure up the “courage to overcome their anxieties in raising concern”[xii] among junior doctors to improve patient care. This problem that student nurses have of not having the courage to overcome their anxieties, is not just with junior doctors, but also with senior staff. They have a fear of addressing concerning issues with senior staff in the fear of being shunned. This creates a “sense of invisibility in the relationship”[xiii] with the senior staffs, especially when they are viewed as mere students and not future of the profession. It is also said that there is a “lack of comfort”[xiv] in communication with others, which has an adverse impact on nursing care. Hence, a positive relationship between student nurse and senior staff is required.
Communication can be written too, which we call as record keeping, which is a legal document in patient care. The student fails to communicate well either orally or in written form – concern rose by the student mentor and the team. Cares are omitted because of lack of communication which will finally affect the safety of patient care. According to NMC code of conduct – If not documented the care is not given. So, communication through the form of documentation is very important. During my supervision sessions, I have noticed that the student was incompetent in the documentation of information in the patient record. To ensure, the problem is solved, I have addressed the student regarding the issue and showed her can I do it or how the documentation had to be done. In order, to improve the overall communication skills of the nursing students, I have implemented the SBAR and Huddle communication method in my supervision sessions. The SBAR approach is standard and is used to transfer information from one person to another. This approach focuses on four aspects (Situation, Background, Assessment and Recommendation) which gives precise information regarding the patient’s status. However, I prefer using the Huddle method in my supervision as I feel that its effective in passing out the required information and is an excellent means of communicating. Using the huddle method of communication, I have observed the reduced number of errors in communication. Overall, communication is an issue in nursing amongst student but with precaution and proper education along with participation in social activities can reduce bad communication.
Another issue found amongst nursing student was the inability to effectively manage time. According to corporate finance institute, ‘Time management is the process of planning and controlling how much time to spend on specific activities ‘. Good time management allows an individual to achieve more in a shorter period, lowers the amount of stress and leads to a successful career. According to nursing time management, Delegation, communication and prioritization are all important aspects of patient safety and care. The student fails to understand the critical value of time management in patient care. In the 21st century troubles with problematic internet use, absorbs student’s attention completely that they are captives to modern technologies and fail other tasks. Society no longer has “a healthy internet use”[xv], this condition is been seen predominantly amongst young people and students. Healthy internet uses are defined by Ceyhan as “when people use the internet to achieve desired results in a reasonable time, without any intellectual or behavioural discomfort”[xvi]. Hence it is said that “College [University] students are at greater risk in matters of excessive Internet use and Internet addiction”[xvii] than any other age groups. Recent studies show that this addiction among students may lead to the “display [of] serious degradation in social, academic, economic, professional or physical areas of their lives”[xviii]. This addiction restricts academic and social success, as well as their health. Students who are addicted to the usage of internet lack time management skills, as they fail to plan and complete projects and papers, or haphazardly complete assignments. The lack of time management among students does not allow them enough involvement in social activities. It is said that effective time management is directly related to academic success among college students. And when students are unable to manage time properly, their academic performance decrease leading to a further reduction of time spent on personal and social activities, reducing satisfaction with life. Studies done among nursing students show that the longer students spend on the internet, the lower their time management skill even though it is not a clear-cut issue among nursing students. During my supervision session, I have noticed my student have issues managing time effectively which was evident in-patient care. The cause of the issue may not be predominantly due to the inappropriate use of the internet, but issues of time management are evident. The team post-handover failed to plan their work, which affected the patient care along with their diagnosis. One of my students, during handover, failed to do the required weight check on a patient prior to breakfast, which was important for the patients as their diagnosis was CCF and they were on diuretics. This incident shows, that the student didn’t plan and as a result failed to assess the patient properly. In another incident, the student failed to pass on information. The doctor had asked to do some blood for the patient (including INR) after the administration of Vitamin K. The student failed to pass this information as she was overwhelmed with other tasks due to her lack of time management skills and the ability to prioritise tasks.
Delegation is also a vital aspect of time management. It would be a difficult task for an individual to complete all task by themselves and ensure that the patient care provided is up to standard. Delegation of work allows effective patient care reducing the limitation of the team. For the skill of delegation to be effectively used, a high level of communication skill is required. [xix]The delegation-communication difficulties are complex and occur across a variety of experience levels of nurses and HCA. Nurses often delay the decision to delegate to individuals of lower pay grade due to potential incompetency or at times they don’t possess the communication skills to delegate in the appropriate manner. It can also be said that nurses find it difficult to different tasks that are to be delegated and those that can’t be delegated along with job description responsibilities. In order to improve this circumstance, the management staffs need to support a culture of proper delegation-communication use among nurses and assistive personnel to maintain the quality and safety standards for patients. Although there are implications in the delegation, this can be solved by using the huddle communication method after reporting times for RN and UAP (Unlicensed Assistive Personnel). This will increase face-to-face interactions, promoting mindful communication techniques and opportunities for sharing of salient information and delegation. During supervision sessions, I have noticed that student nurses fail to delegate trivial tasks to UAP. This is because they lack the ability to prioritise tasks to enhance patient care, and in lacking this ability the slow down the recovery of the patient and put more pressure on other staff to rectify the mistakes. The student under supervision was required to analyse the patient, monitoring their weight for diagnosis to assess the patient’s recovery. However, the student failed to do so and went on about her day to day ADL (Activities of Daily Living) including washing, feeding and toileting. The student could have delegated the ADL tasks to health care assistants and carried out the important tasks. This showed that the student lacked the ability to prioritize, delegate and in return failed to provide appropriate care. It also shows bad management of time as important tasks are sometimes neglected for trivial tasks.
Prioritization is defined as the action or process of deciding the relative importance or urgency of a thing or things as per the Oxford Dictionary. Nursing prioritization is a vital part of the job and questions on the NCLEX-RN are going to assure the test candidates can appropriately distinguish priority nursing actions. Prioritization allows individuals to effectively manage time and resources to achieve a goal either long term or ones that are of a short period. Using Maslow’s Hierarchy of needs what order care must be given in or what steps must come first. Prioritizing daily tasks is key to successful time management. When tasks are prioritized according to the urgency, it is possible to ensure that a high standard of care is given to patients. Therefore, time management is an issue that arises during supervision sessions due to the student’s inability to prioritize workload and to delegate the workload to other members of the team. Due to the lack of the student ability to manage time effectively, they are unable to handover effectively to other teams and are unable to document the care they have provided through documentation. In the supervision session, I use the huddle communication method to address the issue of time management and help students to prioritize and delegate tasks to ensure a high standard of care is given to the patients. Though time management is an issue, I believe this can be solved through communication and guidance on how to effectively manage time through prioritization and delegation of task.
Finally, a lack of insight into performance is one of the issues among student nurses. Patient safety is the priority and for that standard, the student nurses and qualified nurses need to have knowledge (practical and theoretical) regarding patient care. Many students tend to underperform during the practical part of their education period because they lack in theoretical and practical knowledge regarding patient care. In such circumstances, as a mentor, it creates a further issue in grading the student’s ability in a practical situation. The competency-based education system aims to generate ‘a nursing workforce with the skills and flexibility’ to function within global-markets and fulfil employer requirements for graduates who are fit to start employment without the need for extensive training.[xx] As a mentor, I am required to ensure that student nurses demonstrate effective application of knowledge, judgement and skill and achieve set learning outcomes to advance on their programme of study and ultimately qualify to practice independently. The struggle facing mentors is the assessment of competence in practice, which tends to be complex. In the UK, NMC sets out standards for mentors, creating an academic, legal and professional responsibility for them to teach, supervise and evaluate students’ clinical performance appropriately ensuring good clinical practice and excellent patient care. It is required that mentors only confirm a student as proficient if they feel that they have achieved the required standard of competency. But where a mentor fails to fail an under performing student, it implicates patient protection and safety as well as create legal consequences and implications. Following the incident, the debriefing session was arranged. Its time for reflection using Gibb’s model which includes description, feelings, evaluation, analysis, conclusion and action plan. And where student nurses fail to exhibit the required skills despite various support and help rendered by the team, as a mentor, I need to follow the protocol for failing the student first time and an extension for the second attempt has been agreed along with the university guidelines. Thus, creates an adverse situation emotionally for the student as well as the whole team.
During my supervision session, I had a third-year student on her practical placement, who on a regular basis was under performing in all tasks. The student under my supervision was assigned a patient with the cardiac issue, she was responsible for the complete patient care. During the handover, the student was informed about the condition of the patient and given specific instructions if there were to be an emergency and what measures must be taken. Before starting the day’s work, the huddle method of communication was made about the situation of the patient and care and the aims of the supervision session. The student was assigned to care for four patients. One of the patients was unresponsive. The student lacked knowledge of how to deal with the situation and started to shake the patient continually. She failed to prioritize her actions and lacked in understanding the implications of unresponsiveness for a long period. The student failed to communicate to the team by calling for help and a cardiac arrest call. The student forgot to apply the theory of organ failures if not taken appropriate actions at the right time. Rather than following the emergency action plan, the student tried to act by herself. She failed to recognize the issue, select the appropriate action plan and call for help where she lacked the understanding of what to do. There comes a question of patient safety. As a mentor, I had to make more action plan for the under performance student. In order to avoid student failing various measures can be taken in terms of education to help the student perform better. Studies were done on modelling on skill performance[xxi], has suggested that modelling videos for student nurses during pre-briefing are an effective teaching strategy. The study also states that the participant who viewed the expert role modelling video scored significantly higher on the skills checklist than those who didn’t. The results suggest that a visual aid would be beneficial to students, especially those in health care, to ensure that the right patient care is given and the action to take in case of a medical emergency. It is certainly possible for a nursing student to improve their skills and knowledge using modelling videos. It is certain that lack of insight is an immense problem amongst nursing student, and if no action is taken, it would lead to poor health care amongst newly qualified nurses in the workforce. Even though the lack of insight is a problem, I believe with the right training method and taking advantage of student resilience to succeed, it is possible to overcome the issue of lack of insight.
Conclusion
In conclusion, the supervision session is an essential tool in nursing to equip student nurses with interpersonal skills and professional skills to be assets to the workforce. It also provides the student’s a platform to put their education into practice under the supervision of an expert to guide them. Using this means, it refines the quality of work the students are to produce on their placement. Even though supervision sessions are a useful tool, it also has its own issues as discussed above. In my session, I have noticed issues with communication, time management and lack of insight, however, it is not limited to these issues above. There are numerous issues that can arise in supervision sessions which depends on the ability of the student and the capability of the mentor. Where there are issues with supervision sessions, there are also solutions with careful planning. As a mentor, it is essential to ensure that all possible measures are taken in order to avoid issues and that the student’s educational experience is pleasant. When facing issues in my supervision session, I took several measures to overcome the issues in future sessions. In order to overcome the issue with communication, I used the huddle method of communication before and after to pass essential information to the student, including their responsibility and the actions. To overcome the issue of lack of insight, I have used simulation and actions plans to help student gain knowledge and practical skills. Regarding the issue with time management, I have used allocation practice and delegation skills to equip the students to manage time effectively. Therefore, it is possible to overcome obstacles that arise in supervision sessions through careful analysis and planning.
Word Count- 4922
[i] Proctor, B. (1987). Supervision: A cooperative exercise in accountability. In M. Marken, & M. Payne (Eds.). Enabling and ensuring supervision in practice. Leicester: Youth Beaurau and Council for Education and Training in Youth and Community Work.
[ii] Proctor, B. (1987). Supervision: A cooperative exercise in accountability. In M. Marken, & M. Payne (Eds.). Enabling and ensuring supervision in practice. Leicester: Youth Beaurau and Council for Education and Training in Youth and Community Work.
[iii] Proctor, B. (1987). Supervision: A cooperative exercise in accountability. In M. Marken, & M. Payne (Eds.). Enabling and ensuring supervision in practice. Leicester: Youth Beaurau and Council for Education and Training in Youth and Community Work.
[iv] Dabney, B.W; Linton, M; Duncan, C; Koonmen, J. (2018). Measuring the Gap Between Students’ Expectations and Experiences in an RN-to-BSN Nursing Program. Nursing Education Perspectives; Vol.40 (no.1) p. 41-43.
[v] Proctor, B. (1987). Supervision: A cooperative exercise in accountability. In M. Marken, & M. Payne (Eds.). Enabling and ensuring supervision in practice. Leicester: Youth Beaurau and Council for Education and Training in Youth and Community Work.
[vi] Emory, J; Kippenbrock, T; Lee, P; Miller, M.T; Reimers, J. (2018). Communication apprehension and willingness to listen in nursing education. Journal of Professional Nursing; vol.34 (no.4); p284-288
[vii] Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Oxford: Further Education Unit.
[viii] NMC code of conduct. Retrieved on the 30th March 2019 from- https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-old-code-2015.pdf
[ix] Emory, J; Kippenbrock, T; Lee, P; Miller, M.T; Reimers, J. (2018). Communication apprehension and willingness to listen in nursing education. Journal of Professional Nursing; vol.34 (no.4); p284-288
[x] Durmaz, Y.C; Serin, E.K; Polat, H.T. (2018). Determination of Problem- Solving and Communication Skills of Nursing/ Midwifery Students. International Journal of Caring Sciences, Vol. 11(no.3), p. 1771-1777.
[xi] Durmaz, Y.C; Serin, E.K; Polat, H.T. (2018). Determination of Problem- Solving and Communication Skills of Nursing/ Midwifery Students. International Journal of Caring Sciences, Vol. 11(no.3), p. 1771-1777.
[xii] Smith, S. (2019) Communication skills: placement reflections of a children’s nursing student. Nursing Children & Young People; vol 31 (no.1) p.19-23
[xiii] Walker, M. (2018). Strengthening the Relationship Between Nursing Students and RNs During Clinicals. Imprint, vol. 65 (no.4), p.45-47.
[xiv] Emory, J; Kippenbrock, T; Lee, P; Miller, M.T; Reimers, J. (2018). Communication apprehension and willingness to listen in nursing education. Journal of Professional Nursing; vol.34 (no.4); p284-288
[xv] Cerit, B; Citak, B. N; Ak, B. (2018). Relationship between smartphone addiction of nursing department students and their communication skills. Contemporary Nurse: A Journal for the Australian Nursing Profession; vol.54 (no.4/5); p.532-542.
[xvi] Cerit, B; Citak, B. N; Ak, B. (2018). Relationship between smartphone addiction of nursing department students and their communication skills. Contemporary Nurse: A Journal for the Australian Nursing Profession; vol.54 (no.4/5); p.532-542.
[xvii] Cerit, B; Citak, B. N; Ak, B. (2018). Relationship between smartphone addiction of nursing department students and their communication skills. Contemporary Nurse: A Journal for the Australian Nursing Profession; vol.54 (no.4/5); p.532-542.
[xviii] Cerit, B; Citak, B. N; Ak, B. (2018). Relationship between smartphone addiction of nursing department students and their communication skills. Contemporary Nurse: A Journal for the Australian Nursing Profession; vol.54 (no.4/5); p.532-542.
[xix] Guitard, V. (2017). What is the Difference Between the Assignment and the Delegation of Nursing Care? Info Nursing; vol.48 (no.2); p.25-26
[xx] North, H; Kennedy, M; Wray, J. (2019). Are mentors failing to fail underperforming student nurses? An integrative literature review. British Journal of Nursing; vol (no.4); p.250-255
[xxi] Jarvill, M; Kelly, S; Kerbs, H. (2018). Effect of Expert Role Modeling on Skill Performance in Simulation. Clinical Simulation in Nursing; Vol 24; p.25-29
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