Document Type : Original articles
Authors
1 M.sc.Nursing Administration Faculty of Nursing-Assuit University
2 Professor of Nursing Administration, Faculty of Nursing ,Cairo University
3 Professor of Nursing Administration, Faculty of nursing – Minia University
Abstract
Highlights
Heba Dakrory Ali1; Nehad Ezz Eldin Abdallah2; Sahar Ahmed Abood3
1 M.sc.Nursing Administration Faculty of Nursing-Assuit University.
2Professor of Nursing Administration, Faculty of Nursing ,Cairo University
3 Professor of Nursing Administration, Faculty of nursing – Minia University.
Keywords
Introduction
Clinical supervision provides nurses the opportunity to improve quality of patient care and maintaining standards of care provided. In addition, clinical supervision (CS) provides an avenue for nurses to demonstrate active support for each other as professional colleagues, and providing reassurance and validation (1).
Clinical supervision has become a standard practice for health professionals, and considered to be an important component of the comprehensive clinical governance. Also, CS has been promoted as a key of clinical governance component to ensure the provision of and accountability for the quality of care provided to patients, and to minimizing the risk of adverse outcome. Therefore, improving the quality of care in practice is a challenge for both manager and staff (2).
Moreover, the vital position that held by first-line nurse managers is viewed as the most essential link in the nursing department. Also, many nurses and nurse managers feel that the most future task for them is clinical supervision. So, most of head nurse's functions are concerned with supervision, development of the moral, interest, and satisfaction of the staff nurses in their unit (3).
Furthermore, the position of head nurses is vital at each unit and is one of the most difficult, demanding, and challenging jobs in any organization; where they should assess and evaluate the work performance of nurses, review completed medical forms to assess record keeping abilities, and inspect work areas for organization (4).
Clinical supervisor had to be able to assist and support supervisees in the best possible way, and should demonstrate commitment and empathy. Empathetic supervisors are more successful because they understand what makes supervisees tick and can customize their approaches in order to reach others. In addition, they know how to give supportive, positive feedback, and encouragement (5).
In addition, clinical supervisor should be active, open, and constructively help supervisees to effectively explore and develop clinical practice and allow them to discuss clinical and critical issues openly as the culture of clinical discussion seemed to develop in a more open manner and direction of clinical supervisor. Within these boundaries, explicit parameters should be made with regard to issues which could be addressed and which should not. Also, the work discussion that takes place in CS time offers a sustaining environment for nurses to develop their competencies (6).
Significance of the Study
During the clinical training of the nursing students at Minia University Hospitals, it was observed that first-line nurse managers have little knowledge and experience about personnel management especially staff supervision at different situations in clinical care areas. First-line nurse managers might be aware of the concept of staff supervision but they are lacking the knowledge and sound principles of effective supervision. Effective CS may increase nurses’ perceptions of organizational support and improve their commitment to the organization's vision and goals. CS is helping nurses to avoid medical errors and job-related stress, enhance well-being and improves clinical performance which in turn, leads to improved quality of patient care, clinical decision making abilities of nurses and patient safety. Therefore, carrying out an educational program about CS for first line nurse managers may help them to apply effective leadership behaviors in the field.
Aim of the study:
The aim of this study was to investigate the effect of an educational program about clinical supervision for first line nurse managers on quality of their clinical supervision.
Research Hypothesis:
Subjects and method
Research design:
Quasi-experimental design was utilized in this study.
Setting:
The study was carried out at Minia University Hospitals (Minia University Hospital; and Gynecology, Obstetric and Pediatric University Hospitals) .
Subjects
A convience sample of all available first-line nurse managers' were included in the study (total no= 50 nurse) and staff nurses (تلغى was included in the study) (total no 300 nurse) .
Tools of data collection:
Three tools were used in this study: Clinical supervision knowledge questionnaire, Manchester Clinical Supervision Scale (MCSS), and Clinical Supervisor self-assessment questionnaire.
Tool I: Clinical supervision knowledge questionnaire, this tool was included two parts as follows:
1st part was including: Socio-demographic characteristics data sheet for first-line nurse mangers.
2nd part: Clinical supervision knowledge questionaire was developed by the researcher based on related literature (7.8.9.10.11) to assess first-line nurse managers' level of knowledge regarding clinical supervision. The scoring system of this tool was divided as follows: Low clinical supervision knowledge (<60%), moderate (60% - >75%), high clinical supervision knowledge (<75% or more).
Tool II: Clinical Supervisor self-assessment questionnaire
This tool was developed by Bond and Holland (2010)12, this tool was categorized by the researcher into7 subscales to measure the quality of the clinical supervision. The tool consisted of 45 items categorized into 7 subscales namely; trust/rapport (four items), supervisor advise/support (six items), improved care/skills (nine items), importance/ value of clinical supervision (ten items), finding time (five items), reflection (sixth items) and personal issues (five items).The questionnaire consisted of 45 items.
Responses was rated on 5 points likert scale ranging from (5) strongly agree to (1) strongly disagree. The scoring system of this tool was classified as follows: Low level of effectiveness of the clinical supervision (<50%), moderate (50% - > 75%) and high level of effectiveness of the clinical supervision< 75 %.
Tool III: Manchester Clinical Supervision Scale (MCSS), this tool was included two parts as follows:
1st part was including: Socio-demographic characteristics data sheet was developed by the researcher for staff nurses.
2nd part: Manchester Clinical Supervision Scale (MCSS) was developed by Winstanley (2000) 13, and was adapted by the researcher to measure supervisees' perceptions about the quality and effectiveness of the clinical supervision that provided by first-line nurse managers. The scale consisted of 36 items categorized in 7 subscales namely; trust/rapport (seven items), supervisor advise/support (six items), improved care/skills (seven items), importance/ value of clinical supervision (six items), finding time (four items), reflection (three items) and personal issues (three items).
Responses was rated on 5 point likert scale ranging from (5) strongly agree to (1) strongly disagree. The scoring system of this tool will be classified as follows: Low level of effectiveness of the clinical supervision (<50%), moderate (50% >75%) and high level of effectiveness of the clinical supervision< 75 %.
Validity and reliability
Content validity of the three tools were revised and validated by three experts in the field of study which classified as follows: two Assistant professors of Nursing Administration Department – Faculty of Nursing – Minia University and Assistant professor of Nursing Administration Department – Faculty of Nursing – Assuit University. Accordingly some items were modified. The reliability for the study tools were done using alpha coefficient to measure the internal consistency reliability of the three tools; it was (0.77) for Clinical supervision knowledge questionnaire, (0.92) for (MCSS), and (0.89) for Clinical Supervisor self-assessment questionnaire.
Pilot Study
A pilot study for the three tools was conducted on 5 head nurses and 30 staff nurses (10%) that were included in the study subjects, selected randomly from the different hospitals departments in order to check applicability of the tools; identify obstacles and problems that may be encountered during data collection and the estimate time needed to fill the questionnaires. In the light of the findings of the pilot study, no changes occurred in the tools and the tools were put in their final form.
Procedure
The study was conducted in three phases: Assessment and planning phase, implementation phase, and evaluation phase.
Assessment and planning phase
Pre-test was done before implementing program using tool (I) Knowledge test and (II) Clinical Supervisor self-assessment questionnaire for the first line nurse manager, and tool (III) Manchester Clinical Supervision Scale for the staff nurses
The program was implemented for three sub-groups, each subgroup contained from 15 to 20 head nurses, and the researcher applied the program for each sub-group on separate time. All sessions were occurred within the working time of the participants in the hospital education building and teaching room.
In the first session the researcher explained the aim of the study, program objectives, content and time table.
At the beginning of each session, the objective of the session was explained. Daily feedback was done about the previous session and at the end of each session there a summary was provided.
The training program was implemented in three months from the beginning of June 2017 to the end of September 2017.
Evaluation of Clinical Supervision Training Program:
Evaluation of the training program was carried out after implementation of clinical supervision training program for first-line nurse managers using the following tools; the post-test knowledge and Clinical Supervisor self-assessment questionnaire; as well as post-test done for staff nurses using Manchester Clinical Supervision Scale. The post test was done three times; first immediately after implementation, after three months, and follow-up after 6 months.
Ethical considerations
Statistical Analysis
Data were analyzed using the statistical package for social science (SPSS) version 20. Numerical data were expressed as mean and SD. Quantitative data were expressed as frequency and percentage. For quantitative data, comparison between two variables was done using t-test, and comparison between more than two variables used ANOVA test. Relations between different numerical variables were tested using Pearson correlation. Probability (p-value) less than 0.05 was considered significant and less than 0.001 was considered highly significant.
Results
Table (1): Demographic characteristics of the study subjects (First line managers' and staff nurses)
Demographic characteristics |
First line managers (50) |
Staff Nurses (300) |
|||
No |
% |
No |
% |
||
1. Age |
|
|
|||
> 20-30 31-40 < 40
|
6 20 24 |
12 40 48 |
74 121 105 |
24.7 40.3 35
|
|
Mean ± SD |
37.82 ± 6 |
34.82 ± 6 |
|||
2. Sex |
|
|
|||
Male Female |
2 48 |
4 96 |
72 228 |
24 76 |
|
3.Marital status |
|
|
|||
Single Married Divorce Widowed |
14 30 5 1 |
28 60 10 2 |
57 207 18 18 |
19 69 6 6 |
|
4.Qualifications |
|
|
|||
Diploma Institute Baccalaureate other |
0 0 42 8 |
0.0 0.0 84 16 |
128 136 46 0 |
42.7 45.3 12 0.0 |
|
5.Years of experience |
|
|
|||
1-10 11-20 < 20 |
9 19 22 |
18 38 44 |
114 104 82 |
38 34.7 27.3 |
|
Mean ± SD |
15.92 ±6.4 |
14.92 ± 6.4 |
|||
6. Area |
|
|
|||
General Critical |
39 11 |
78 22 |
222 78 |
74 26 |
|
Table (1) shows that48% of first line managers were in the age group 40 years or more . The majority of the sample (96%) were females (60%) were married, the majority (84%) of them had baccalaureate degree of nursing, nearly to half تلغىmore than one third (44%) had more than 20 years of experience.
Regarding personal and job characteristics of staff nurses, table (1) revealed that more than one third (40.3%) of them, were in the age between 29-39 years, while (76%) of them were females, about two thirds (69%) were married, less than (45.3%) of them had technical degree of nursing, and more than one third (38%) had experiences ranged from 1to10 years.
P1= pre and post the program implementation P2 = pre and after three months of program implementation
P3= pre and after sixth months of program implementation
Figure (1): Total level of CS knowledge of first line managers’ during different times of testing (n=50)
Figure (1) shows that (76%) of first line managers had low level of knowledge, while (10%) of them had high level of knowledge in pre-test. While at the immediate post-test it was (76%) of them had high level of knowledge and (12%) of them had low knowledge. After three months of program implementation there was little change in knowledge level between first line managers, (72%) of them had high level of knowledge and (16%) of them had low knowledge. While after sixth months of program implementation the knowledge level had decrease , (64%) had high level of knowledge and (24%) of them had low level of knowledge with statistically significant differences (p=0.001).
Figure (4): Comparison between first line managers' self-assessment and nurses' Perception about clinical supervision at three different times of measures
In figure (4) it was observed that only (10%) of first line managers' self-assessment and (10.7%) of staff nurses' perception of head nurses had high level of CS before program implementation; while after program implementation, more than three quarter (78%) of first line managers' self-assessment and (79%) nurses' perceptions had high level of CS. These scores were gradually decreased after three and sixth months, with statistically significant differences (p=0.001).
Discussion
Clinical supervision is essential for reducing errors which ultimately leading to improve the quality of patient care and safety. Also, inadequate and/or poorly coordinated supervision of the less experienced or unskilled staff is harmful to patients and increases stress and burnout in health professionals. Further, inadequate clinical supervision may also lead to the acceptance of lower standards of care, because health professionals may not be able to contextualize their practice, without appropriate supervision14.
The current study revealed that 48% of first line managers were in the age group 40 years or more with mean age 37.82± 6. This might be attributed to all most of first line managers' graduated from faculty of nursing and take at least 2-5 years bed side nurse or more. Regarding to sex , the majority of the study sample were females. This result might be attributed to that majority of nurses who graduated from Secondary School of Nursing, Technical Institution of Nursing, and Faculty of Nursing were females also the fact that females are still the main gender in the nursing profession. Regarding years of experience, the present study revealed that less than half (46%)of the studied first line managers had 21-35 years of experience with mean 15.92 ±32.1 6.4.
Findings of the present study revealed a high statistically significant improvement in the level of knowledge of first line nurse managers' regarding clinical supervision at the pretest and the following three times of measurements after implementation of the program. First line nurse managers' had low level of knowledge before program implementation. This level significantly increased to high level immediately after implementation of the program and after the following two periods of measurements (after three and six months).
This result reflected the positive effect of the CS educational program. This finding is consistent with the finding of Morsy, (2014) (4) who conduct a study about the effectiveness of implementing clinical supervision models on head nurses' performance and nurses' job satisfaction , which (. تلغىMorsy, (2014) (4) study results) revealed that, there were high statistically significant improvements of both head nurses and their assistants' knowledge and responsibility (perception) about clinical supervision after implementation of the program. Also this was agreed with Cruz et al.,(2012) (15) who conduct a study on clinical supervision in nursing; and it was supported that participants emphasized all dimensions of CS; as well there were improvement in knowledge and CS levels.
The result of the present study indicated that there were significant differences in overall first line managers' self-assessment and nurses' perceptions of clinical supervision between the pretest and the three measuring times after the program implementation. The total mean score of clinical supervision increased from low level before the program implementation to high level immediately after implementation unexpectedly, there were slight gradual decrease in the level of the clinical supervision after three months and after sixth months of the program implementation with statistically significant difference.
This could be attributed to the changes in first line managers' knowledge about CS which affect their performance on CS after implementing of the training program. As, first-line nurse managers learned and gained knowledge from all topics of clinical supervision and its' elements as well as the essential skills and how to implement the clinical supervision for nurses.While the slight decrease in the quality of CS could be attributed to forgetting which was compensated by giving the first line manegers handouts about the programe contents (CS).
This result was supported by Edward et al., (2016) 7 who indicated that, training on clinical supervision could result in changes in the attitudes, values and, behaviors of clinical supervisor as well as the supervisees' perception of their managers. Also, Hancox et al., (2014) (16) reported that, provision of training program about clinical supervision for nurse-managers has been effective and affect the attitude of both nurse managers and nurses ; and results in clinical supervisors' understanding of clinical supervision and its' importance and how it could be improved.
The result of the present study indicated that first line managers' had high level of CS at critical areas more than general areas in pre and post program implementation. This might be due to shortage of nurses, increase in workload, and number of patients, shortage in equipment and crowded work environment in units in the general area, all of this lead to low performance of first line managers in the general areas.
This was consistent with Mohamed et al., (2016) (17) who attributed that to the nature of work environment in the general care unit, which lead nurses to low performance of patient care due to crowded areas with physicians, nurses and students from different nursing and medical schools, Where they must interact constantly with other staff members, visitors and physicians and there was no control on achieving an appropriate workload.
Moreover, this was consistent with Berland et al., (2008) (18) who mentioned that increasing job demands were a problem for nurses. It could have consequences for patient safety in relation to inadequate time to properly test equipment and insufficient time for the preparation of medications. In addition, daily control routines in the morning could not be completed.
Conclusion
There were statistical significant differences between pre and the three measures of posttest regarding the knowledge and level of CS for the first line managers; and perceptions of nurses about CS provided by first line managers.
The total mean score of clinical supervision increased from low level before the program implementation to high level immediately after the implementation, and then there were slight gradual decrease of the level of clinical supervision after three and sixth months of the program implementation with statistically significant difference.
Recommendations
Based on the findings of the current study it was recommended that