Perceptions and Attitudes of Mental Health Nurses to Clinical Supervision

Abstract

Clinical supervision is recognised as a valuable resource due to the stressful nature of mental health nursing. For mental health nurses, clinical supervision has become an important strategy aimed at providing support and on-going professional development to enable them to improve their practice and the quality of client care. Clinical supervision is an activity that is interpreted widely in terms of its definition, purpose and its practical application to the practice of mental health nursing. Despite methodological limitations in research, in general terms the weight of evidence significantly supports the view that clinical supervision is effective. It is seen to enhance professional and personal development, provide support in the clinical workplace and consequently by direct and indirect means, facilitates improvement in the provision of care.

The main objective of this study was to identify and describe the perceptions and attitudes of mental health nurses to clinical supervision. Of the seven participants whom participated in the study four had recent experience of clinical supervision and the remaining three mental health nurses did not have any recent experience of it. Both cohorts were asked a series of questions  within the framework of semi-structures interviews which also allowed for further description and exploration on their perceptions and attitudes to clinical supervision.

Following an interpretative phenomenological analysis of the interview transcripts, major themes on the participants perceptions and attitudes became evident.  The results identified the main themes from the data which included; the understanding that clinical supervision provides a number of function, that there are specific factors which are necessary for supervisees to experience within the supervisory space, that a number of factors impact on attending supervision and finally the challenges which were identified to the provision of clinical supervision within the respondents working environment.

In conclusion, the results of this research indicated that mental health nurses had different understandings and experiences of clinical supervision but their overall perception of supervision was a positive one and all respondents reported that they would welcome the opportunity to undertake clinical supervision within their practice. For those nurses currently receiving supervision this was as a result of further training within cognitive behaviour therapy (CBT) and psychotherapy. However for those nurses whom hadn’t undertaken further academic development and whom worked within an acute mental health setting the onus on clinical supervision to support both their personal and professional practice was distinctly lacking. This appeared to be related to a number of factors which included; the absence of priority given to clinical supervision for staff, the attitudes of staff themselves towards supervision, and organisational issues in terms of resources. Supervision structures for all disciplines are recommended to facilitate learning within clinical practice areas (Milne 2009), and there is a need for organisational and cultural change in order to create a positive movement towards integrating clinical supervision into professional practice.

Chapter 1: Introduction

1.1 Introduction

Widely accepted as an essential component of professional practice in what are commonly referred to as the ‘helping professions’, supervision is a phenomenon that is defined and practiced in a myriad of different ways. Often a contested practice suggestive of both surveillance and support, supervision can be provided formally by an experienced and qualified professional and informally by colleagues and peers. Many promote it as an essential process to validate professional identity, develop the reflective capacity of workers, encourage a solution focused approach to practice and enhance experiential learning.

Others argue that it is increasingly being used purely as a managerial tool to monitor targets, outcomes and accountability. Like many phenomena, its impact is largely influenced by who is providing it, how it is being provided and the extent to which its provision is underpinned and informed by an empirically sound paradigm.

This thesis provides an account of mental health nurses’ perception and attitudes of clinical supervision from a phenomenological perspective. The participants were recruited from within the Health Service Executive- South (HSE-S) region. Semi-structured interviews were conducted which were audio taped and transcribed verbatim, to examine the lived experiences of the participants’. Interpretative Phenomenological Analysis (IPA) (Smith 1996; Smith and Osborne 2003) was utilised to analyse the collected data and to identify the main themes.

This chapter presents the background to the study, the aims of the study and the rationale for the study, a brief overview of the methodology and an outline of the dissertation. Literature relating to clinical supervision and mental health nursing formed the basis of this study. The literature included in the review met the following criteria:

English language publication related to clinical supervision and mental health nursing from 1975-2013.

The following databases were used to review the literature:

PsychINFO, PsychARTICLES, and Pub Med. The Google search engine was utilised, the University College Cork (UCC) on line library and the Health Services Executive (HSE) Library, Bantry were also used to access journals and books relevant to the study. The search terms included clinical supervision, mental health nursing, psychiatric nursing, supervision.

1.2 Background to the study

The profession of mental health nursing, within the previous decade has seen the role of mental health nurse advanced significantly. This is predominantly in relation to their clinical role and responsibilities, in order to provide, responsive recovery focused interventions, which are evidence based practices (DoHC 2008b). In 2012 the mental health nursing profession in Ireland in consultation and collaboration with a number of contributors published a strategy for the future advancement of mental health nursing practice. This report prepared by Cusack and Killary (2012) titled ‘A Vision for Psychiatric/Mental Health care in Ireland – a shared journey for Mental Health care in Ireland’ advocated a number of recommendations to support the delivery of a person centred, recovery focused, quality and safe mental health service. The requirement for ‘clinical supervision ‘ was the first recommendation in this strategic document and it  endorses that clinical supervision be made available to all nurses and undertaken by all nurses to ensure the principles relating to recovery values within mental health nursing are enhanced.

This recommendation is in keeping with international evidence supporting the significance of clinical supervision within mental health nursing (Butterworth et al 2008). Further to this Lynch et al (2008) argue that CS is deemed a fundamental element for the establishment of a robust and effective mental health nursing workforce. However, the evidence base for the inclusion of clinical supervision as a support structure for mental health nurses is limited.

Clinical supervision has emerged both internationally and in Ireland as a means of using reflective practice and shared experiences to support continuous professional development whilst the practice of clinical supervision is currently being heralded into the profession of mental health nursing at an international level, within an Irish context, there is a paucity of literature relating this area. In 2015 the Health Service Executive (HSE) delivered a  ‘Clinical Supervision Framework for Nurses Working in the Mental Health Service’ (HSE 2015) and specifically directs the development and delivery of a clinical supervision system for the mental health nursing profession.

1.3 Aims of the study

The purpose of this current study was; to explore mental health nurses  perception and attitude towards clinical supervision to gain a greater understanding and uncover the essence of mental health nurses perception and attitudes and ascertain the role and relevance of CS within their practice.

1.4 Rationale for  the study

The idea for this research was generated from various sources; firstly the personal and professional experiences of the researcher who had received clinical supervision in a previous role and is not currently in a position to undertake clinical supervision in their current role.

Secondly, from a review of the literature, evidence suggests that both patients and staff benefit from mental health nurses undertaking clinical supervision () and it is influenced by the belief that supervision is an invaluable learning tool in supporting mental health nurses to develop professionally and to respond  effectively to changes in policy and practice within their operational environments. The research is timely given the development of mental health nursing in recent years particularly in relation to their clinical role and responsibility in order to provide responsive care and the changing environments that mental health nurses are encountering within their individual areas of. Specifically the research attempts to understand the current perceptions and attitudes to supervision within the profession of mental health  nursing; describe how supervision is provided; define the purpose and value of supervision as it is perceived by mental health nurses; highlight the challenges that present in providing supervision and identify areas that could be improved or developed in order to enhance the experience of supervision within mental health nursing.

1.5 Methodological overview

Phenomenology is a philosophy that is concerned with the question of how individuals make sense of their world (Bryman 2008). A phenomenological approach was adopted in this study to capture the perceptions and attitudes  of the mental health nurses in relation to clinical supervision. In total eight mental health nurses, four of whom  had experienced clinical supervision and four of whom had not experienced it recently agreed to take part in the study.

Semi-structured interviews were conducted with the participants; the data was recorded and transcribed verbatim. Interpretative Phenomenological Analysis (IPA) Smith (1996); Smith and Osborne (2003) was utilised to analyse the data to guide the identification of the main themes and to establish the results, which were then discussed in relation to the relevant literature.

1.6 The Structure of the Study

This chapter has outlined a qualitative method of exploring mental health nurses perceptions and attitudes of clinical supervision. The research question, the background to the study, the aims, rationale, and methodology utilised in the study have been identified in this introduction Chapter 1.

The literature review in Chapter 2 presents the key discourses relating to the research topic.

The rationale and the objectives for the research, together with the research design and the methodology that was used in its execution, are explained in Chapter 3. The ethical considerations as well as the limitations of the research are highlighted.

The findings from the semi-structured interviews are described in detail, in Chapter 4.

Chapter 5 discusses the research findings and their implications with reference to the wider literature.

The main themes and arguments are drawn into an overall conclusion in Chapter 6.

It is hoped that the research findings will impact on the current understanding of supervision within mental health  nursing will generate debate on contemporary practice and strengthen and inform future supervision practice in mental health nursing.

Chapter 2: Literature review

2.1 Introduction

The clinical healthcare environment is progressively becoming more complex and challenging. Health professionals contend with inadequate resources, staff shortages, greater demand for clinical services, along with increased complexity and acuity of patients (Health Workforce Australia 2010). Within this challenging setting it has been contended that clinical supervision may safeguard the strains around what is anticipated and what is achievable in relation to such issues as person-centred care, implementation of clinical practice guidelines and utilisation of research in an increasingly evidence-based healthcare environment (Australian Resource Centre for Healthcare Innovations [ARCHI], 2012; Butterworth et al 2008; McCormack and McCance, 2006).

There is a significant body of literature on the subject of clinical supervision and the aim of this thesis is to present a comprehensive overview of the major themes and concepts that are relevant to the research. The objective is to provide a broad background and justification for the study. The review begins by tracing the development of supervision. A number of fundamental definitions are explored and its key functions are described. The identified challenges to enabling the implementation of clinical supervision within the mental health environment are explored.

2.2 Terminology

There is considerable crossover between the literature on supervision in mental health  nursing and supervision in other forms of nursing. This review therefore incorporates literature on nursing supervision in general with a particular focus on clinical supervision within mental health nursing. The variety of descriptors used with the word ‘supervision’ reflects the association of supervision with many different models, practices and disciplines. Within the nursing literature supervision is usually discussed as clinical supervision. As a concept clinical supervision is generally regarded as poorly defined. Therefore in relation to this current literature review the term supervision will be used  to indicate a cluster of related concepts and use descriptors such as clinical to situate the use of the term within particular theoretical and disciplinary field.

2.3 Background context

Historically the development of clinical supervision has gone hand in hand with the activities of the field of social work and was underpinned by professionally defined notions of ‘competent’ and ‘accountable’ practice (Kadushin and Harkness, 2002). Supervision first emerged in the United States towards the end of the 19th century. It was created as a teaching forum within the charitable sector, with paid social work staff managing a volunteer workforce (Busse, 2009). Emerging initially as an administrative task, closely followed by the developing emphasis on education and support, its focus has shifted over time, mirroring the role of social work within society and the organisational context within which it operates (Wonnacott, 2012).

Although supervision is now relevant to all fields of human services and has become mandatory practice in many, the practice of supervision is often very differently understood and interpreted (Davys and Beddoe 2010). Even as a growing body of literature endorses the concept of CS, descriptions vary regarding what that means operationally and what it should encompass to be effective (Hines-martin and  Robinson 2006). Increasingly, as it  has developed as a professional activity in its own right, supervision is practiced across a range of professions in an array of organisational and private settings (Davys and Beddoe 2010). To date the majority of the research related to clinical supervision and mental health nursing originates from Australia and the United Kingdom. Much of this research has been published within the past fifteen years with little or patchy updates emerging on this subject.

Research has also indicated that there are many variables associated with mental health nurses experiences of CS including overall clarity on its availability, whether it is mandatory or voluntary and  on who needs and receives it within the service.  As a result of the complexity and diversity of the contexts in which it is implemented, the literature reports confusion about the role and structure of clinical supervision; a diffuse unlinked evidence base; challenges measuring the effectiveness of clinical supervision and difficulty in implementing clinical supervision in practice (Dilworth et al 2013). 

2.3.1 An Irish Context

The expansion of supervision practice in the health and social care professions can be linked to the growing culture of regulation and compliance within these professions and the explicit linking of supervision to driving quality and accountability (Beddoe, 2010; 2012). O’Neill (2004) suggests that the combination of public disquiet at the level of emerging scandals and abuse in Irish society and services, the growing body of legislation relating to accountability and the public expectation for higher standards and measurable outcomes all point to the need for a recognised framework for accountable practice and for the on-going development of staff in a supervised and supportive environment.

While supervision has been recognised as a valuable and necessary component of practice among some disciplines in Ireland, and a  sustained growth in the utilisation of C.S has been identified (NMPDU 2008) the introduction of structured supervision is still a relatively new undertaking for many others and Morrissey (2008) has highlighted that within the mental health setting this process remains at an emergent stage.

Mental health nursing are the largest profession working within the Irish Mental Health services. Over the past decade the role of the nurse has developed significantly particularly in relation to their clinical role and responsibilities in order to provide responsive care.

Concurrent with this development in clinical practice the working environment within which it is undertaken has become more complex and challenging. Coupled with these environmental changes there are a number of organisational national and international legislative and policy frameworks and guidelines which further guide practice. A number of these policies and frameworks underpin the need for the use of clinical supervision to support both the practice of the mental health nurses and the impact this has on the service user.

HIQA Standards for Safer better Healthcare Theme 6 – Workforce outlines the following:

Standard 6.3 Service providers ensure their workforce have the competencies required to deliver high quality, safe and reliable healthcare.

6.3.3 Facilitation of members of the workforce to maintain necessary competencies to meet their relevant professional registration requirements.

6.3.6 Supervision, monitoring and review of the provision of care to ensure all members of the workforce work within their competencies. 

A Vision for Psychiatric/Mental Health Nursing – a shared journey for mental healthcare in Ireland (Cusack and Killory 2012) outlined a number of recommendations to support the delivery of a person centred, recovery focused, quality and safe mental health service.

Recommendation 1: outlined the requirement for clinical supervision: “Clinical supervision shall be made available internally to all nurses and to be availed of by all nurses to ensure recovery values and principles have been translated and maintained in clinical practice”. 

The HSE published national supervision guidance (HSE HR Circular 002/2015) to support and strengthen the quality of care and staff engagement with the goal of improving and maintaining safe, quality, effective and efficient care for services users (HSE 2015) . This clinical supervision framework for nurses working within the Mental Health services compliments these HSE National supervision guidelines and specifically directs the development and delivery of a clinical supervision system for the nursing profession working in Mental Health services.

However, despite the evidence within the literature and the focus of the health service to build the capacity, skills and competence within mental health nursing in Ireland, clinical supervision remains an elusive concept. 

2.4 Definitions of Clinical Supervision

Supervision is acknowledged as an essential component of professional practice that provides a chance for the supervisee to reflect on personal and professional needs in order to improve performance and to receive support (Fone 2006).Within nursing, definitions of Clinical Supervision has been abundant (Winstanley and White 2003). In endeavouring to define clinical supervision, the relationship between definition and purpose are intertwined and therefore challenging to separate as the definition will inexorably describe the purpose to some degree also (Cowie 2011). The concept of Clinical Supervision is associated with a wide diversity of context, aims, philosophies and practices however Cowie (2011) reports that clinical supervision is a practice that fails to propose a solitary categorical definition.

This has required individual professions to cultivate an operational definition reflective of their explicit requirements. In relation to nursing, Francke and Graff (2012) refer to the supervisor and use of reflection as the technique for clinical supervision offering a definition of C.S. as “an activity that brings skilled supervisors and nurses together in order to reflect upon their practice” (Francke and Graff 2012, p.1166).

Buus et al (2011) offer:

“Clinical Supervision is a formalized pedagogical process where nurses, individually or in groups, discuss work related issues with a qualified supervisor. The purpose of C.S. is to improve the quality of nursing care by directing, developing and supporting nurses”. (Buus et al 2011,p.95)

This definition identifies the process of supervision in relation to who undertakes it the method and the rationale for utilising it. Specific to mental health nursing Cleary et al (2010) refer to a “semi structured process where a mental health nurse (the supervisee) meets regularly and confidentially with a more experienced practitioner (the supervisor) to discuss issues of relevance to the supervisees practice”. (Cleary et al 2010, p.525)

Cleary et als’ (2010) definition embraces the concept of theoretical diversity signifying that there is a multiplicity of definitions of supervision and Cleary et al (2010) further advocate for the mental health nurses themselves who partake in C.S. to actually define it. Additional to these definitions, from an Irish nursing perspective, An Bord Altranais has utilised Butterworth and Faugier (1992, p.12) definition of CS as “exchange between practising professionals to enable the development of professional skills”.

In an attempt to provide an overarching view of clinical supervision Davys and Beddoe (2010) scrutinized the practice of supervision in different groups of professionals over a period of twenty years. They advocate that supervision is more reflective of applying professional skills, knowledge and principles rather that observing rules. Further, C.S can provide an arena to critically engage in reflective practice in terms of actions and decisions.

Specific to the profession of mental health nursing Buus and Gonge (2009) conducted a systematic review of 34 empirical studies in relation to clinical supervision and reflected the lack of clear definitions  relating to clinical supervision which is considered by Buus and Gonge (2009) as a serious impediment to direct the process in which the expansion of C.S empirical research is determined in the future.

Milne (2010) further concluded from a logical analysis they undertook that an empirical definition is required in order for research and practice relating to C.S to progress into the future. Cleary et al (2010) advocates that a definition of C.S should incorporate a distinct understanding of what can be credibly accomplished through supervision,  thereby providing an  understanding of supervision relative to what it is anticipated to accomplish.

2.5 Models of Clinical supervision

A supervision model according to Ross (2013) is a conceptual framework that can contribute to the delivery of clinical supervision. Bernard and Goodyear (2009) advocate that the qualities of an effective model of clinical supervision need to focus on the learning and developmental needs of the supervisee, the specific needs of the patient , the organisational goals and within the legal and ethical boundaries of practice.

In exploring the possibility of developing a standardised CS model for mental health and addiction nurses by Mckenna et al (2010) the majority of respondents in the mixed methods research considered a nationally agreed approach beneficial. Nonetheless, there is acknowledgement that the sample participants in McKenna et al (2010) research were purposefully selected and therefore cannot be considered as representative of other target populations.  The research revealed that failure to utilised a particular theoretical model was indicated by 70% of the managers. Despite the positive outcome towards a nationally agreed approach one of the respondents  asserted that  being bound to a particular model would create a lack of flexibility and limitation in the approach to supervision. Similarly Buus and Gonge (2009) identified that the distinctive nature of mental health nursing did not lend itself to a specific model or theory of CS.

International literature has indicated that when models of professional supervision have been effectively implemented supervision increases nurses feelings of support and personal well-being, enables reflection on knowledge and practice and increases staff morale and satisfaction (Cleary and Freeman 2006). Within the Irish healthcare experience differing models, approaches and systems of clinical supervision are employed (HSE 2015).

Despite the difference in approaches to supervision the HSE outline in their circular (HSE HR Circula 002/2015) that the appropriateness of which model is applied is dependent on a number of significant factors including, the level of experience of the practitioner, the demands or requirements of the particular professional body and the resources and opportunities available.

A number of model of clinical supervision have been discussed in the literature however the Proctor Model of Clinical Supervision (Proctor 1986) has become one of the most influential and widely adopted model to be implemented in nursing context (White and Winstanley 2011). The frequently cited Proctor’s model consists of three components which are described as restorative, formative and normative (Best, 2008; Winstanley, 2000). The restorative area is concerned with checking for work distress and burnout, the formative area critically examines clinical interventions and develops clinical skill and the normative area deals with professional issues including codes of practice and boundaries (Best, 2008; Winstanley, 2000).

Contrary to the reported benefits of this model in capturing the functions of CS Buus and Gonge (2009) conclude that the Proctor model does not consider clinical outcomes or organisational factors affecting clinical supervision and should be extended to address these issues. Sloan et al (2000) asserts that the model is too imprecise, failing to identify interventions appropriate to each domain (Sloan et al., 2000). Further to this the issue may be further compounded by the results of a synthesis of CS definitions/components, which suggested that the normative and restorative components of CS be deleted as they were not supported by the evidence (Milne 2007). This absence of CS model clarity, together with the lack of definitional clarity adds to the confusion around developing a working understanding of effective CS and its application into practice for mental health nurses.

Gonge and Buus (2011) conducted a cross sectional questionnaire survey to test the applicability of a model for investigating the benefits of clinical supervision and utilised the Manchester Clinical Supervision Scale  (MCSS) (Winstanley 2000) to measure the effectiveness of clinical supervision. Results indicated that actual participation in a number of clinical supervision sessions in order to experience the tangible effectiveness of the supervision was essential. However, acknowledgement of serious limitations to the validity of the study are outlined by Gonge and Buus (2011) with consideration given to the design type and method of data collection and recall biased. Nonetheless, the study was supportive of the recommended model but attentiveness to the methodological restrictions were emphasized.

2.6 Benefits of Clinical Supervision

The nature of nursing work, irrespective of the care setting is defined by Currid (2009) as stressful however Hanrahan et al (2010) reports than mental health nurses have twice the risk of verbal aggression and burn out than other nursing professions.

2.6.1 Benefits for Nurses

Addo et al (2012) conducted a systematic review to elicit the best available qualitative evidence experienced by mental health/psychiatric nurses in relation to the benefits of clinical supervision. They selected qualitative papers which were independently assessed for methodological quality. The results highlighted that clinical supervision allows for opportunities to experience the Restorative aspect of Proctors model (1986) of clinical supervision and is considered a critical and integral role in mental health nursing and patient care.

Buus and Gonge (2012) conducted a sequential mixed methods study to scrutinize the factors impacting on psychiatric nurses participation in clinical supervision. The benefits of clinical supervision in psychiatric nursing were acknowledge  however a number of factors including allocated time, trust in the process and energy to participate were highlighted as necessary to experience effective clinical supervision. This is similar to the study by Koivu et al (2012) with the results of their questionnaire to female hospital nurses (n=304) indicating that receiving efficient clinical supervision was indicative of feeling better supported both personally and professionally with a higher incidence of motivation and commitment than those not attending supervision.

Wright (2012) reported a positive correlation for nursing staff between participation in C.S and development of their professional skills and competence, prevention of staff burn out and an improvement in job satisfaction. Brunero and Stein-Padbury (2008) report that many supervisees also highlight personal growth as a reward from CS which can also reduce isolation and enhance communication and networking and can help nurses to manage professional and organisational conflict.

Circenis et al (2015) conducted a quanitative research of 60 practising mental health nurses in Latvia to determine the effectiveness of Clinical Supervision in relation to burnout. The Maslach Burnout Inventory (MBI) (Maslach and Jackson 1986) was used to measure burnout in this study. The results of this research indicated more understanding of themselves and their work for nurses who participated in supervision than in the control group who didn’t undertake supervision. This outcome was similar to the results of a study by Edwards et al (2006) in a Welsh study of 260 community nurses lower levels of burnout were related to high evaluations of clinical supervision on the MCSS. Cutcliffe and Hyrkas’ (2006) study which incorporated a multidisciplinary approach including registered nurses within mental health, also identified clinical supervision as an opportunity to support nurses through the stressful demands of the profession on the condition that line managers were not supervisors, as this was deemed to limit the freedom of supervisees to openly discuss their  thoughts.

Despite the evidence embracing the benefits of C.S, White and Winstanley (2010b) refute many of the identified accounts and propose that from randomised control trial they conducted, these benefits  remain to a large degree uncorroborated. This is further expanded upon by Buus and Gonge (2009) whom undertook a systematic review of empirical studies of supervision in mental health nursing and concluded that the research methods and designs that were utilised were reflective of numerous weaknesses and that the quantifiable effects of C.S were inconclusive. Buus and Gonge (2009) also cautioned that the lack of understanding and transparency in relation to the numerous existing models for undertaking clinical supervision together with lack of agreement as to what clinical supervision necessitates adds to the difficulty in implementing C.S effectively.

Despite the acknowledgement that clinical supervision could provide a range of benefits respondents in a semi-structured interview of twenty two psychiatric hospital nursing staff by Buus et al (2011) highlighted C.S as having minimal influence on their daily clinical work. The benefits of C.S were dependent on the full and continuous support of management and from the nursing staff themselves. Respondents also highlighted that informal peer support was an important tool used for emotional support but they acknowledged that peer support had limited impact on the nurses professional development.

2.6.2 Benefits for Patients

There is indication in the research literature that competent supervision results in improved patient care outcomes and that it acts as a quality assurance mechanism (Tracey et al 2014; Watkins, 2012). Without supervision the quality control of mental health interventions depends on the ability of mental health practitioners to self-evaluate their competencies. Self-evaluations prove to be difficult with beginning and lower skilled clinicians who are found to typically over-rate their competencies, which can have negative implications for patient outcomes and safety.

In relation to the benefits of clinical supervision for patients White and Winstanley (2010) conducted a randomised control trial in Queensland which was further augmented by qualitative data collection to compliment the quantitative data collected. The objective was to examine the relationships between supervision, quality of nursing care and its impact on patients. The results indicated that in all but one location (a private sector mental health setting) there were no significant differences in terms clinical supervision and quality of patient care or level of satisfaction. This outcome is contrary to a quasi-experiment study by Bradshaw et al (2007) that investigated patient outcomes in a mental health setting and identified that a reduction in patients positive symptom correlated with being treated by students actively engaged in C.S compared to no reduction in symptoms with a group of patients treated by students not engaged in C.S. Butterworth et al (2008) concluded from a systematic review of literature that positive effects for staff were evidenced in the literature but the impact of supervision in relation to patient outcomes regarding quality of care and patient safety were limited. Severinsson (2012) advocates for the inclusion of these factors – quality of care and patient safety – as a measurement of supervisory effectiveness within the Manchester Clinical Supervision Survey as he suggests that the theoretical scope of the MCSS may be too limited. Buus and Gonge (2013) counter this and suggest that the inclusion of issues relating to patients within the MCSS would compromise the MCSS as a measurement tool in relation to the outcomes of Supervision. Brunero and Stein-Padbury (2008) advocate for further study in relation to patient outcomes as an ability to evaluate the effectiveness of C.S.

However, despite a large body of evidence, the strength of the evidence as to the impact of clinical supervision is low (Francke & de Graaff, 2012; Hyrkäs, 2005). Dilworth et al (2013) undertook a literature review on the current debates regarding clinical supervision and they concluded that all of the reviews appear to reach a similar conclusion: the evidence that clinical supervision is effective is not strong and there is a need to address methodological limitations in order to improve the strength of the evidence (Brunero & Stein- Parbury, 2008; Butterworth et al., 2008; Buus & Gonge, 2009; Farnan et al., 2012; Francke & de Graaff, 2012; Gonsalvez & McLeod, 2008; Spence et al., 2001; Wheeler & Richards, 2007; Williamson & Dodds, 1999).

Dilworth et al (2013) further discussed that the analysis within these individual pieces of research rarely takes into account confounding factors and researchers’ preconceptions (Buus & Gonge, 2009; Spence et al., 2001). The use of supervisee or supervisor as the single source of data adds a potential bias in that there may be a difference between what they do and what they say they do (Heaven et al., 2006; Spence et al., 2001). Feedback from supervisees about the supervisor performance is also likely to be systematically biased due to the power differential in the relationship (Gonsalvez & McLeod, 2008). The role of researchers  as supervisors may also introduce bias (Buus & Gonge, 2009). However, despite these concerns, there is reluctance to dismiss the potential benefits of supervision and programmes of supervision continue to be implemented internationally and across disciplines (Alleyne & Jumaa, 2007; Brunero & Lamont, 2012; Health Workforce Australia, 2011 ). 

2.7 Factors that Influence Effective Clinical Supervision

Effective Clinical Supervision is described by Falender and Shafranske (2014) as a process within a supervisory relationship in which the supervisee is enthused to develop themselves in their practice thereby augmenting  the outcome for the patient whilst also being attentive of the need to safeguard the patient.

2.7.1 Supervisory Relationship

Cerinus (2005) highlighted the quality of the relationship between the supervisor and supervisee is indicative of the quality of supervision. This action research study highlighted the central importance of  being able to select the supervisor and an effective environment.

Trust and confidence in the clinical supervision relationships were also highlighted as important. The respondents in a semi structured interview conducted by Buus et al (2011) of 22 mental health nursing staff participating in group supervision underlined the necessity for the supervisor to be external to the particular ward as it was felt  that an internal supervisor would compete with  the same restrictions as staff members. Buus et al (2011) outline that it is not possible to credibly transfer the data findings to other mental health settings due to probable biases associated with the level of participation in C.S and the  influence of work place factors on participants responses.  Cleary et al (2010) suggests that in order to strengthen the supervisory relationship the supervisor needs to display empathy and remain non-judgemental and furthermore provide the opportunity to explore difficulties and problems in order to validate and support the supervisee. Exploring the supervisory relationship of community mental health nurses, Sloan (2006) found that supervision discussions could be unboundaried with the supervisee encouraged to discuss anything including aspects of their personal life. Supervisors were line managers and supervision was dominated by the managerial agenda with a focus on problem solving and risk management.

Sloan (2006) argued that this meant that supervision did not give enough attention to the therapeutic relationship and found that at one case site supervisees experienced supervision as actively “ detrimental” and felt “trapped” and felt unable to address the problem with their supervisor/line manager (Sloan 2006: 132).

2.7.2 Environment within which clinical supervision is provided

Edwards et al (2006) used the Manchester Clinical Supervision Scale (MCSS) to survey community mental health nurses in wales. They found that nurses evaluated C.S more positively when sessions took place away from the ward environment, lasted more than an hour and were held at least once a month. Also using the MCSS,Hyrkas (2005) found that the majority of respondents in his study had one to one supervision, had chosen their supervisor and had sessions of at least one hour. Frequency and duration of session and the ability to choose their supervisor were associated with effective C.S (Hykras 2005).

2.7.3  Organisational Factors

Resistance to clinical supervision is perpetuated by organisational culture within healthcare that is suspicious of change. In this context time, staffing and budgets are used as an excuse by organisational management to maintain current practices (White & Winstanley, 2009).

Ability to attend supervision sessions according to Gonge and Buus (2010) in a review of empirical studies of C.S for mental health nurses may depend on managerial support or on logistical factors such as shift work. This was also identified by McTiernan and McDonald (2015) whom highlighted organisational structures and processes and increasing workload as opposed to client issues as factors which impacted on nurses experiences of stress. Gonge and Buus (2010) found that community based mental health  nurses were considerably more likely to participate in C.S than in-patient nurses and that nurses working an evening shift were less likely than day shift nursing staff to attend. They did acknowledge however that the research designs utilised in the studies failed to capture the complexity of C.S.

Of paramount importance according to Cleary et al (2010) is the requirement for C.S to be consistent and continuous as haphazard CS will strengthen the commonly shared uncertainty with regard to CS and add credibility to the credence that it has limited significance. Gonge and Buus (2011) identified a correlation between effective supervision and level of participation in it. Lynch et al (2008) has identified the significance of supervisors receiving appropriate training and preferably being accredited by a reliable professional organisation. White and Winstanley (2010b) advocate that a more positive outcome for clinical supervision is determined by the level of preparedness of the supervisee and their working environments supportive of clinical supervision.

A randomised control trial by Gonge and Buus (2015) indicated that having the facility to attend C.S on a regular basis lead to participants in their intervention group being easier to motivate to participate in C.S more frequently than participants in the control group. The researchers reported methodological challenges thereby inferring that this research topic is difficult to investigate scientifically with implication in terms of validity of empirical evidence.

2.7.4 Management Providing Supervision

Supervisors play a key role in Clinical Supervision (Brunero and Stein-padbury 2008) however the involvement of managers as clinical supervisors has been problematized in the literature. Participants in Buus et al (2010) study identified the importance of a supervisor who was external to the work place. Cutcliffe and Hyrkas (2006) comment on the evidence that practitioners believe that a supervisor should not be in a managerial relationship to the supervisee as this is likely to cause a confusion of roles. Conversely, despite general agreement that C.S should be separate from management in practice it is sometimes used to meet management requirements (Sloan 2006). Health Service Directors implementing C.S among mental health nurses in Northern Ireland reported that it was difficult to separate C.S from managerial purposes perhaps because supervision was provided by line managers (Rice et al 2007). It is argued that supervision should not have a managerial purpose and that managerial aims including professional accountability should be achieved through specific managerial supervision (Sloan 2006; Cutcliffe and Hyrkas 2006).

In a large scale introduction of clinical supervision in the mental health services in Queensland Australia, sceptical or hostile managers obstructed the implementation of supervision particularly through control of the staffing rosters and workloads also impeded participation in supervision (White and Winstanley 2009).

To provide an overview Brunero and Stein-Padbury (2008) conducted a systematic review of literature utilising a number of specified criteria to elicit evidence which was available pertaining to the effectiveness of clinical supervision within nursing practice. Proctors (1986) three functions of C.S – normative, formative and restorative – were used to categorise the results. The research indicated that the provision of clinical supervision was reflective of nurses experiencing the restorative aspects of Proctors model and a reduction in the levels of stress. 

2.8 Issues relating to implementation of Clinical Supervision

Many acute mental health inpatient settings continue to struggle with the notion of clinical supervision and the implementation process (Cleary et al 2010) although it is considered as significant for the formation and conservation of a robust and effective mental health nursing workforce (Lynch et al 2008). Lynch and Happell (2008a, 2008b 2008c) report that variations in terms of the practice of C.S within inpatient units are apparent which consequently negates the capacity to implement them successfully. 

2.8.1 Organisational factors

A survey of clinical supervision practice in Northern Ireland revealed that a lack of clear guidelines and models of supervision to assist with implementing and evaluating clinical supervision are barriers to its implementation (Rice et al 2007). . Sloan and Grant (2012) contend that when the organisation arbitrates the delivery of C.S it can result in ineffective and inconsistent outcomes. Adequate resources, regional guidelines to implement  a mixture of models by adequately trained supervisors were identified by Rice et al (2007) as fundamental to the implementation of C.S. Turner and Hill (2011) conducted a study to implement Proctors (1987) model of C.S and evaluate the results. Although the study sample was small the results indicated that the implementation of regular and structured clinical supervision was beneficial. The study also highlighted that Proctors model could be used as a stepping stone in implementing C.S in mental health services but investment in C.S was paramount to ensure high standards of care for patients.

In order to contextualise the provision of clinical supervision for mental health nurses and allied health professional’s (AHP’s) within an NHS board in Scotland  Cookson et al (2014) undertook a questionnaire. Findings indicate that clinical supervision is being implemented in agreement with guidelines however, AHP’s received C.S more than nurses, and community staff were more likely to receive it than inpatient staff. Cruz and Carvalho (2012) highlight the absence of instruments to evaluate clinical supervision in nursing has added to the difficulties related to its implementation and development within the field of nursing. 

White and Winstanley (2010) indicate that managerial position required a solitary, interconnected and unambiguous stance in order to support the implementation of CS.

2.8.2 Nurses Responses

Within the broader framework of a randomized controlled trial (RCT) of CS, White and Winstanley (2010) conducted semi-structured interviews to categorize important factors relating to an attempt to implement CS in Australia. Suspiciousness of staff and their level of commitment towards the process of CS, substandard culture of utilising CS and the potential cost implications were identified as issues fundamental to the difficulties in implementing CS. Cruz et al (2014) undertook an action research to relate the implementation of C.S model with supervised nurses identifying the response to the stress and the coping resources they used. The results indicated that through the use of clinical supervision the quality of care provided to patients improves and it further reduces the stress experienced but enhances nurses ability to cope.

2.9 The role of clinical supervision to support the use of cognitive behaviour therapy practice by mental health professionals

On-going efforts to improve mental health services in the Ireland have identified the need for mental health nurses to include psychological treatments into their practice. In particular, cognitive behaviour therapy (CBT) has been identified as the main focus of those psychological therapies (DoHC 2006). The ‘Reach Out’ Programme, Improving Access to Psychological Treatments (IAPT 2008), is a training initiative based on CBT, which was developed to train practitioners in low intensity psychological interventions in the United Kingdom (UK). O Shea et al. (2010) established a comparable training model for the Irish Mental Health Service which aimed to augment skills for clinical practice for mental health professionals who deliver psychosocial interventions to clients as part of their every day practice. The programme content was constructed upon principles and methods of evidence-based CBT practice, and was aligned with the transformation in service delivery within the Irish  mental health system aimed to facilitate and promote ‘service user recovery’ in mental health services. The Mental Health Commission (MHC) ‘The Quality Framework for Mental Health Services in Ireland’ (2007), emphasized three fundamental enablers for service users to a quality mental health service which are; staff skills, competencies and expertise.

Further to this, the MHC ‘A Scoping Study’ (2010), identified that respondents acknowledged the need to cultivate  competencies in psychotherapeutic interventions such as ‘cognitive behaviour skills’ and emphasized that these skills should be included for all mental health professionals.

Cusack and Killoury (2012) recommended that nurses increase their clinical capacity through the development of a range of skills and interventions and that evidence-based practice should inform clinical practice and service delivery. The ‘Guiding Framework’ on the proposed Certificate in CBT (HSE, 2013) suggests that mental health nurses and other care professionals are well placed to deliver evidence-based interventions (such as CBT skills) to achieve a recovery orientated mental health service. However, a crucial factor in learning and applying CBT in practice is clinical supervision (Grey et al 2008) and that sustained supervision over a prolonged period may be necessary to maintain competency gains (Lopez and Ramirez Basco 2011). This was further supported by Smith et al (2012) whom ascertained that workshops individually, did not modify clinical practice but advocate that one to one supervision could contribute to new skills being conveyed in to clinical practice.

Therefore in order that mental health professionals are able to maintain competence within their enhanced areas of delivery of evidence based practices including CBT the on-going provision of clinical supervision is crucial (Cusack and Killoury 2012). This was also reiterated by Mannix et al (2006) whom identified in their study, that fifty per cent of the trainees randomized to discontinue supervision reported deterioration in their use of CBT skills after six months.

2.10 Conclusion

The literature review provides a background to the research. Established definitions and discourse on the function of supervision are outlined in light of the critical role that it plays in supporting workers in relation to their efficacy and well-being. There is a growing recognition, within the helping professions, of the importance of professional standards and the need for greater accountability. There is also widespread acknowledgement of the value of providing effective supervision and supporting the professional development of all workers. Supervision can be viewed narrowly as a management tool and the growing emphasis on providing it could be solely attributed to changes in public sector management and the need for greater efficiencies. However, the literature also contests that the contemporary landscape of the practice of supervision can be linked to an increasing commitment to high standards of delivery and a focus on practice outcomes. It is now widely accepted that good practice approaches advocate a strengths-based, accessible and flexible service that is needs led and delivered in partnership with families, professionals and communities.

In order to integrate the many strands within the review of the literature in the area of clinical supervision it is important to reflect on the salient points. The changing face of mental health nursing within the last decade has highlighted a need for support and reflection. However a number of challenges are identified including the lack of consensus in relation to a definition and model of clinical supervision to meet the specific needs of mental health nurses.

Although the benefits of clinical supervision have been addressed and the factors which are required to support these benefits discussed  the issue of implementing clinical supervision continues. Taylor and Harrison (2010) indicate the strength of evidence within the literature gives further credence of the necessity of mental health professionals afforded the opportunity to explore their clinical practice experiences through clinical supervision. The challenge therefore is to comprehend the existing personal and professional experiences of mental health nurse in relation to clinical supervision.

Research Methodology

3.1 Introduction

This chapter offers a rationale for the research and describes the methodology that was utilised to achieve it. The aim and objectives of the study are defined and the research design, which provided a framework for the collection and the analysis of the data, is outlined in detail. The sampling procedures or specific methods of investigation that were used to collect the data that informed the research are explained and defended. How the data was analysed is explained and the extent to which further data collection was influenced by the initial findings of the study is described. Some of the limitations of the study are highlighted along with the problems that were encountered in sampling and completing the data collection.

Finally, the ethical issues encountered during the research process are explained.

3.3 Research Paradigms

A paradigm refers to a set of beliefs that guides the researcher’s approach to inquiry (Crookes & Davies 2004). Two main paradigms dominate nursing research today, qualitative and quantitative. Qualitative research is defined by Polit & Beck (2010: 565) as the ‘investigation of phenomena, typically in an in-depth and holistic fashion, through the collaboration of rich narrative materials using a flexible research design’.

Quantitative research is defined as the ‘investigation of phenomena that lend themselves to precise measurement and quantification, often involving a rigorous and controlled design’ (Polit & Beck 2010: 565).

Rational for Qualitative research

The primary strength of qualitative research is its potential to explore a topic in depth (Carlsen & Glenton 2011).The philosophical underpinnings of qualitative research are interpretive, humanistic and naturalistic and aim to uncover life experiences and give them meaning (Burns & Grove 2007). It does this by ascribing meaning to subjective experience.

Rutter (2006) comments that qualitative research is a developmental process. She believes that openness to emerging ideas or concepts enables the determination and exploration of key factors during the process of research itself. Trochim and Donnelly (2006) state that qualitative methods are chosen to gain experience with the phenomenon, because it is highly effective for investigating complex and sensitive issues and because it produces information that is very detailed.

Therefore a qualitative inquiry was deemed the most valid approach to investigate the research question which sought to explore mental health nurses lived experiences of CS. The phenomenological approach assisted with accessing and capturing more focused thoughts and subjective experiences of the participants through semi-structured interviews with the option of follow-on questions to further explore the essences of the experiences. The data is retained in its original form of meaning and in not in any way quantified.

Grounded theory was discounted from as a research approach whilst acknowledging it within the umbrella of qualitative research it seeks to produce a theory as its end point. It is too early to develop a theory on the research subject in hand.

Rational for Interpretative Phenomenological Analysis

Interpretative Phenomenological Analysis (IPA) is a qualitative approach to understanding participants’ lived experiences in order to describe what a topic is like for them within a specific context (Larkin et al 2008; Smith 2004). IPA is informed by three key positions: phenomenology, hermeneutics and idiography (Smith et al 2013).

Phenomenology describes the “what” and “how” of individuals experienced phenomena, develops descriptions of the essences of experiences, but does not explain or analyse descriptions (Creswell, 2013).

Hermeneutics is a theory of interpretation concerning textual meaning, as in the techniques used in speaking and writing that divulge the intentions and context of the speaker/writer (Smith et al., 2013). Finally, idiography relates to details and thorough analysis of small cases, which differs from mainstream psychologocial studies that are nomothetic in nature (Smith et al., 2013). 

Researcher’s Preconceptions

Sandelowski (2010) notes that the researcher will inevitably hold some preconceptions; they cannot be completely open-minded. She believes that preconceptions should be understood and communicated, but equally that they may be challenged and can change over the course of the study in response to emerging information. Kvale (1996) acknowledges that to find one correct, objective and true meaning is not a requirement of many forms of research and that multiple interpretations are both possible and valid. By the researcher identifying their preconceptions on a subject, they become more aware of interpretive possibilities (Sandelowski, 2010) and therefore are better able to “…suspend judgement and prior knowledge about the experience and phenomena…” (Lauterbach, 2007, p. 219).

The researcher identified three preconceptions held prior to conducting the study. The first was that clinical supervision is an effective process to develop nursing practice.

The second was that the supervisor‟s ability in a clinical supervision context is vital to achieving effective outcomes.

The third was that supervisee motivation is a defining factor in determining supervision effectiveness. 

Qualitative research is described as suitable for the study of human experience in nursing and has increased in use over the last three decades (Schneider et al 2007). In contrast to quantitative research where process and meaning are structured and measured, qualitative research describes process and meaning in terms of intensity, patterning and frequency (Denzin and Lincoln 2000).

Phenomenology is a philosophy that is concerned with the question of how individuals make sense of their world (Bryman, 2008).The qualitative research method aims to capture the experience and meanings of individual and groups (Carter and Henderson, 2005). Braun and Clarke (2013) suggest that qualitative research is concerned with ‘meanings and the ways people make meanings’. Silverman (2005) states that richer data on the understanding of social phenomenon can be derived from qualitative research methods rather than by utilising quantative data.

3.5 Population, Sample and Sampling

Participant selection should have a clear rationale and fulfil a specific purpose related to the research question, which is why qualitative methods are commonly described as ‘purposive’ (Collingridge & Gantt 2008). Participant selection must be congruent with the conceptual framework. Participants should be likely to generate rich, dense, focused information on the research question to allow the researcher to provide a convincing account of the phenomenon (Walsh & Downe 2006).

The population for the current study was eight consenting mental health nurses working within an Irish rural mental health unit which serves a population of between (400,000 to 500,000) people (Health Service Executive 2010b). A population is defined as the total number of subjects, which information can be obtained, that meet the inclusion criteria (Polit & Beck 2010).

The primary consideration when making sampling decisions was that the voice of the individuals was heard. Qualitative methods are generally seen as being most effective with small numbers studied in depth (Denzin and Lincoln, 2000; Holloway and Wheeler 2010).

This reflects the high volume of rich data obtained from these methods. Large sample sizes in qualitative research can result in data that has less depth and richness (Holloway & Wheeler, 2010). A further point of consideration in choosing sample size is the data saturation point (Haber, 2010; Houser, 2008). This point is identified when new themes cease to emerge as data is accumulated and analysed. Polit and Tatano Beck (2004) state that there are no rules regarding sample size in qualitative research. They view data saturation as the defining indicator and state that it is highly variable and that judgements are made in response to the “…sufficiency and volume of the data…” (p. 308).

Non probability sampling does not allow an equal chance for the participants to be selected (Parahoo 2006). Therefore, the findings cannot be generalised to the target population.

Within non probability sampling five different methods exist. Convenience and quota sampling are two of these and are mainly used in quantitative research, whereas, purposive sampling, network sampling, and theoretical sampling are more often used in qualitative research.

In qualitative research sampling is “ the process of choosing suitable units of interest so that the focus of the study is can be adequately researched”(Schneider et al., 2007 , p. 123). A purposive sampling technique was used in this study. Schneider et al. (2007) describe purposive sampling as occurring when the researcher selects people with the required status, experience or knowledge to provide the information to answer the research question.

Purposive sampling is often used in qualitative research because the quality of information obtained is much more important than numbers of participants (Patton, 2002). Purposive sampling provides information rich cases for the study in order to gain inside information from the people who are intimately involved. Patton (2002), states that purposefully selected samples focus more deeply on the phenomenon. Information rich cases are those from which a great deal can be learnt about issues that are important to the research purpose.

It is recommended that purposive sampling is utilised in the qualitative research approach, such sampling is strategic and aims for the sample to include people relevant to the research (Bryman 2008). Theoretical sampling ensures that relevant categories emerge from the research process and theoretical saturation occurs when there are no further insights to be gained and no further interviews required (Carter and Henderson, 2005). The potential sample consisted of mental health nurses who experienced clinical supervision, a sample size of between 6 and 10 is recommended in this research approach  (Braun and Clarke, 2013).

Saturation is reached when ‘all questions have been thoroughly explored in detail [and] no new concepts or themes emerge in subsequent interviews’ (Trotter 2012, p. 399). The term saturation initially arose from grounded theory, which is a complex and demanding qualitative research methodology; however, in recent years a significant proportion of qualitative researchers have taken up the term without adhering to its stringent methods of concurrent data collection and analysis for theory development (Carlsen & Glenton 2011) 

3.6 Methods of Data Collection

Engagement is the key to a fruitful interview, as this is the source of unique personal knowledge that elevates qualitative research above boxed answers to standardized questions (Cleary et al 2014) The researcher and participants need to communicate with each other well enough to collaborate because interview responses and in situ observations are ultimately mutually generated and context specific (Graneheim and Lundman 2004). Given that qualitative research is seeking quality and depth, a homogenous group of participants can provide richer answers (Cleary et al 2014). The interviewer, interviewee and interview processes are crucial for eliciting relevant in-depth responses, which may uncover pearls of insight during the analysis phase. Without a rich source of information, the results can only be commonplace, providing no real extension or elaboration upon existing knowledge (ibid).

As a research strategy, interviews are a powerful data collection tool which involves asking questions which may be open-ended, closed-ended or both (Teddlie and Tashakkori 2009).

Semi-structured, face-to-face interviews were conducted for the purpose of this study. The main advantage of face to face interviews is the availability of the interviewer to structure the interview situation and to motivate respondents (De Leeuw 2008). In a semi-structured interview, the interviewer has an interview guide that serves as a checklist of topics to be covered along with a default wording and order for the questions which can be modified, based on the flow of the interview. The advantage of this type of interview is that additional unplanned questions can be asked to follow up on information that is provided during the interview (ibid). Consequently, specific comments and reflections made during the interviews could be explored for wider ranging precedents in order to generate broader conclusions about ways of addressing the identified challenges.

In semi-structured interviews, the base questions are formatted in an order that attempts to approximate predicted information flow, but the actual sequencing depends on the emerging information and responses (Holloway & Wheeler, 2010). Referencing back to the interview guide at intervals ensured that relevant streams of enquiry were not omitted and that the data focus was broadly similar for every participant. As points of interest emerged, brief notes were taken when required so that relevant information was not lost and could be re-visited if indicated.

Data collection in qualitative research is associated with collecting information directly or indirectly from an identified and selected sample population. Various methods of collecting data can be used on their own or in combination with other methods (Schneider et al., 2007).

Sandelowski (2000) stated that qualitative data collection aims to discover “the who, what and where of events and experiences…” (p. 338). The researchers seek to explore the thoughts, feelings, experiences, meaning of experience, interactions, responses, actions and individual and group processes within their social and cultural settings (Schneider et al., 2007). 

The individual interview method also offers both the researcher and the participant a non- threatening and supportive environment (Whitehead and Annells 2007). A semi-structured interview guide was piloted with a colleague and with another independent person. This enabled the researcher to practise and polish interviewing techniques and to identify and rectify any inconsistencies (Roberts and Taylor 2002).

The researcher also utilised prompts in relation clinical supervision (in order to stimulate memories) in the semi-structured interviews and encouraged the participant to feel free to describe their own memories and meanings (Snelgrove and Havitz, 2010). The researcher had an interview guide, questions were developed by exploring the relevant literature related to clinical supervision. Patton (2002) outlines the types of questions relevant for a qualitative interview they include; the behaviour or experience, opinion or belief, feelings, knowledge, sensory and background or demographic information and this was used as a guide. 

3.7 Data Analysis

Accurate reporting of qualitative research methods during all stages is important for reader comprehension and transparency (Cleary et al 2014). Researchers need to have a systematic approach to interpreting transcripts and it is important to clearly represent the subjective thoughts and feelings of respondents ( Walsh and Downe 2006). The researcher should spend time (spread over time) immersed in and dwelling upon transcripts, and thoroughly exploring alternative understandings and re-determining codes, categories, themes and sub-themes (Walsh and Downe 2006, Snyder 2012). . Because interview material has no intrinsic structure, the qualitative data analyser has to seek threads, patterns and ultimately coherence, amongst the jumbled jigsaw pieces in an endeavour to create a clear picture (Snyder 2012).

This is a matter of finding order within chaos, making sense of massed information and condensing it – not simply imposing a template upon the material. Snyder (2012) likens this to ‘fracturing’ and ‘rearranging’ data to develop coding categories. Rigour and transparency in qualitative research demand that there is some form of explicit evidence about the analytic methods used to show how themes were discerned (Walsh and Downe 2006).

The one-to-one interviews generated detailed data. The average duration of each interview was forty minutes and particular attention was taken to ensure that the opinions of the researcher did not influence the responses. Each interview was audiotaped and the tapes were transcribed. Following transcription, the data was read and re-read to develop an overview of the database, note initial ideas and generate appropriate codes. The codes were then clustered to identify a number of themes from the data. Robson (2011) describes this as thematic coding analysis and defines it as a generic approach to the analysis of qualitative data which involves constant comparison analysis to organise the data into similar ‘chunks’ or ‘segments’ followed by grouping the initial codes into a smaller number of themes. Grouping evidence and labelling ideas in this way promotes a broader and more comprehensive interpretation of research data (Creswell and Plano Clark, 2011).

The researcher aimed to pilot the questions for the semi-structured interviews in order to gain experience of asking the questions, to refine any questions that may not have been understood and to see how well the questions would flow (Bryman, 2008). The pilot was tested out on one participant, however it might have been more helpful if the researcher had practiced the interview technique with a colleague as recommended by Braun and Clarke (2013). The researcher found the interview challenging due to various factors; the inexperience of carrying out interviews, the limitations of the interview guide being rather closed, rigid and structured, and the researcher experiencing ‘stage fright’ (Morse and Field, 1995).

3.8 Limitations of the Research

As a small scale study, the results of the study cannot be generalised beyond the research population. Interviewing is a highly subjective technique and there is always the danger of bias (Bell, 1996). Care was taken to ensure that questions were phrased and presented as objectively as possible.

3.9 Ethical Considerations

The nursing profession places emphasis on the value of the individual (Barker & Buchanan-Barker, 2009). This approach is philosophically aligned to the research principles of beneficence, to do good and non-maleficence, to do no harm (Lakeman, 2009). The study has been configured to adhere to these principles. The research method selected is also judged to be able to fulfil what Munhall (2007) identifies as the most important ethical obligation of the qualitative nurse researcher; that is to”….describe the experiences of others in the most faithful way possible” (p. 504).

Ethical research involves getting the informed consent of the research participants as well as reaching agreements about the use of the data and how its analysis will be reported and disseminated (Blaxter, Hughes and Tight, 1998). Sarantakos (2005) claims that efforts have been made in recent years to ensure that research is more accountable and that ethical standards are now an integral part of any research. The basic ethical standards in social research are: proper identification – not giving false impressions; clear information concerning questioning and the research questions; concern with the welfare of the respondents; free and informed consent; right to privacy; right to anonymity and the right to confidentiality (ibid).

In this study participants were fully informed about the purpose of the research as well as the potential benefits of participating in it. Clarity, brevity and frankness are the key considerations in providing information on which consent is based (Walliman, 2005).

The Irish Nursing Board states that nurses must be aware of the ethical principles when undertaking or participating in research (An Bord Altranais 2000b). Following on from this, the Irish Nursing Board developed a document to provide nurses and midwives with guidance on ethical matters relating to research, to ensure the protection of the rights of all those involved in research (An Bord Altranais 2007d). Research conducted must be consistent with the ethical guidelines and principles of the researchers practice (Polit & Beck 2010). Therefore, the writer must be aware of both local and national ethical policies and procedures. The writer adhered to these guidelines by gaining both ethical and local approval to conduct the research (see appendix 5 & 7). The ethical principles that must be adhered to when conducting nursing research include respect for persons/autonomy, beneficence, non-maleficence, justice/fairness, veracity, fidelity and confidentiality. These are now addressed in further detail. 

3.11.1 The Principle of Respect for Human Dignity and Autonomy

People have a right to be treated as autonomous agents and choose if they wish to participate in research (Polit & Beck 2008). In order to respect a person’s right to autonomy and self-determination, the subjects were informed that they had the right not to participate in the study, without prejudice. Informed consent was sought from participants by providing them with information outlining the nature of the study, including the risks and benefits of participation. Postal questionnaires are one of the few data collection methods that allow respondents to maintain anonymity. Measures to ensure anonymity were outlined. This information was conveyed in a letter accompanying the study, allowing the participants to make an informed choice (see appendix 10). Participants were advised that completion of the questionnaire implied consent.

3.11.2 The Principle of Beneficence/Non-Maleficence

Researchers have an ethical duty to balance the potential benefits against potential risks and to minimise potential risks to the greatest possible extent, thus safeguarding and protecting the participants. The principle of beneficence is the promotion of good (Haigh 2008). The generation of new knowledge will contribute to the body of nursing knowledge, benefiting both the individual and society as a whole (Parahoo 2008).

Under the principle of non-maleficence research participants have the right not to be harmed. These principles were borne in mind from the outset of the research design.

The writer ensured that mechanisms were in place to protect participants. The questionnaire and topic chosen were not deemed as a sensitive area. However, participants may feel threatened that their anonymity may not be upheld. Reassurances were provided in the information letter so participants were fully informed of data handling and anonymity. Potential harm was minimised by the writer by ensuring the rights of the participants were not violated. The questionnaires were distributed in sealed envelopes and placed into a sealed envelope and deposited into a box. There was no way of identifying the participants as no coding system was used and participants were not required to give any identifying personal details. Finally, the anonymity of the site where data is collected must be upheld, should the findings be disseminated (Haigh 2008).

3.11.3 Principles of Justice, Veracity and Fidelity

The principle of justice states that the researcher must treat participants equally and fairly, throughout the research process (An Bord Altranais 2007d). In order to achieve this, the writer used systematic random sampling to ensure a non discriminatory sample was obtained. Justice was also borne in mind when data analysis occurred, as it is vital to present the findings objectively (Haigh 2008). Veracity was upheld by ensuring participants were fully informed of all aspects of the study (Parahoo 2006). The principle of fidelity is the building of trust between the researcher and the participants’; this was upheld through the information provided with the study. The participants’ were provided with contact details for the writer, should they have required further information on the study.

In conclusion, using the accepted ethical principles for research as a framework, the ethical implications of the current study have been identified. The methods for safeguarding the rights of the participants in relation to the identified implications have been addressed. These safeguards were applied and implemented throughout the study.

3.10 Conclusion

This chapter has presented the rationale for the research and has described the design and methodology that was used to explore the research questions. The sampling approach and methods of data collection that were employed to investigate the aim and objectives of the study are detailed. Every effort was made to ensure that the research was conducted in accordance with the basic ethical standards of social research.

Chapter 4

4.1 Introduction

In this chapter the findings of the study are presented. The aim of this study was to explore mental health nurses’ understanding and perception of clinical supervision.  The researcher gathered qualitative data from research participants, by conducting seven semi-structured qualitative interviews.

The mental health nurses interviewed for this research were asked to talk in as much detail as possible, on their understanding and perception of clinical supervision (CS). This included their understanding of the process and structure of how it works, the function and role of supervision, the supervisory relationship and the challenges associated with providing supervision. The responses were then transcribed, and the interviewer read and reread the transcriptions in order to become familiar with the data for the purpose of analysis. The transcripts were coded in considerable detail, with the focus transferring back and forth from the main assertions of the participant, to the researcher’s interpretation of the meaning of those claims.

The main themes and subthemes that emerged are described in this chapter. Examples of the subthemes are illustrated in selected verbatim quotes, from the participants’ accounts of their understanding and perceptions. Identifying codes were used to identify the participant, page number and unit of interaction (e.g P3P2.4 = Participant 3, Page 2, Unit 4). The main themes and subthemes that are presented in this chapter are illustrated in figure 1.

4.2 Demographic Information

All participants had a primary qualification as a mental health nurse; however four of the participants were now working at a higher level of practice such as CBT therapist, Psychotherapist, Behaviour Family Therapist and Behavior Therapist.

Table 1

Participant Pseudonym	Age Range	Primary Qualification	Additional Qualification	Practice Years	Experience of Clinical Supervision	Currently attending Clinical Supervision
Maura	50-59	Mental health nurse	None	>20 years	Yes – limited	No
Jim	30-39	Mental health nurse	None	6-10 years	Yes – limited	No
Mick	50-59	Mental health nurse	Behavioural Family Therapist	6-10 years	Yes –regular	Yes
Helen	60-69	Mental health nurse	Behavioural Therapist	>20 years	Yes –regular	Yes
Sean	50-59	Mental health nurse	Cognitive Behaviour Therapist	>20 years	Yes –regular	Yes
Jane	40-49	Mental health nurse	None	16-20 years	Yes –limited	No
Helen	50-59	Mental health nurse	Psychotherapist	>20 years	Yes –regular	Yes

4.3 Main themes

Figure 1:

THEME 1                          THEME 2                  THEME 3                     THEME 4

Provides a number of functions	Factors necessary within supervisory space	Factors which impacts on attendance at clinical supervision	Challenges to providing clinical supervision
Restorative space	Need for staff support	Mandatory attendance or choice to attend	Organisational factors
Space for deeper learning (formative function)	Safety within the space – confidentiality and trust	Need for both individual and/or group supervision	Attitudes of staff towards clinical supervision
Maintain and ensure effectiveness of supervisee everyday practice (normative function)	Qualities of supervisor	External supervision rather than managerial supervision
		Experience in working within mental health

4.3.1 Theme 1: Clinical supervision is perceived as providing a number of functions

Theme one described the participants understanding and perception of clinical supervision as identified by them, following varying degrees of experience of supervision. The three sub themes that emerged within this main theme were; restorative space, formative space and normative space which are reflective of  Proctor’s (1986) Interactive Model of Clinical Supervision. Although all participants had an experience of clinical supervision, three of the participants were not currently accessing clinical supervision within their current clinical roles. There was a general perception that clinical supervision was a necessary and positive experience, and there was an overall sense that, for supervisee to feel safe enough or capable enough to discuss their clinical practice (normative), they firstly need to feel that they are being supported (restorative), and that learning will be part of the process.

4.3.1.1 Clinical supervision offers a restorative space

The participants conveyed a need to feel supported and safe within the supervisory space which would facilitate them to express themselves in an open manner. This was particularly highlighted by those nurses whom were now practising at a more advanced level of professional practice including  psychotherapy and cognitive behavioual therapy. Provision of, a) safe and supportive environment, b) a place to express and unload distress and c) a possibility to feel connected

1. Safe and supportive environment

The participants repeatedly described that experiencing core conditions of empathy, genuineness and non-judgemental by the clinical supervisor and a felt sense of nurturance within clinical supervision were fundamental to being open and honest within the space

P2 P6.2   Jim:  “you want to know that you will be supported, you want to know that you will be listened to, there are some people in society, that think people that work in psychiatry are immune from mental health issues”

P3 P5.4   Mick: “It’s important that you can bring in whatever, to what I consider a safe environment, that it’s non-judgemental”

Many of the participants used Metaphors to describe their sense of being nurtured. Helen describes it as a “Cocoon”, Mick describes his sense of supervision as “something like a protective kind of a mushroom”,

P1 P1.2         Helen: “it’s good to get feedback as well for on a positive note, for things you are doing well, and for highlighting your strengths”.

P4 P7.4       Elen : “It’s a place where you can really be yourself, so  there is a freedom with it to actually say how you really feel”,

Maura describes her personal experience as being supportive and nurturing; however, she was also aware of experiences of confrontational style supervision, which some of her colleagues experienced

P1 P6.4   Maura:   “My experience of it was quite positive… but I found with other people, that it was a totally different experience, it was an argument and they were dreading their sessions of clinical supervision”.

2. It is a space to voice and unburden distress

All participants addressed this with regards to the distress which they experienced within their work and that they needed a safe space to enable them to unburden and voice this.

P6 P2.4    Jane:  “It would allow staff to be listened to, and I suppose that staff feel heard, you know that it would allow staff to get things off their chest as well”

P4 P2.3    Elen:  “It’s somewhere to discuss your baggage… it gives you a place to bring them out and to discuss them and to talk about them rather than to carry them around with you”

P3 P2.1     Mick:    “I think it would help staff from the burn out perspective, if staff don’t feel supported that, with supervision that they can kind of discuss why they are doing things, what’s causing the problems”

3. Need to feel connected

Participants highlighted, that the relationship that developed with the supervisor was important, more especially a sense of being heard within the supervisory session.

P5 P19.2    Sean:   “I think there has to be somebody who you think you can get on with, somebody experienced, they’ve got to be approachable or reliable”

P4 P6.1     Elen:   “It kind of validates what you do, and who you are, to have someone hear you and listen to you”

P6 P7.2    Jane:    “You have to feel that there is a rapport there, that they understand you, and that you do feel listened to”

However, for Maura the experience of not being listened to within supervision created a rupture in the relationship

P1 P7.6   Maura:  “It actually broke towards the end, because she wasn’t listening to what you were saying, I thought she did, but at the end of the day she wasn’t, she didn’t actually listen to what your suggestions were, or what your needs were as a member of staff”

4.3.1.2 Clinical supervision offers a space for deeper learning (Formative Function)

This involves skills and knowledge development. The supervisee has the opportunity to develop new and improved clinical insights

1. Reflective space

The need for reflection was clarified by Sean who identified the need to reflect and incorporate this into practice

P5 P1.2   Sean: “You can talk about clients that you are struggling with, and clients that you are doing well with, you can reflect a spectrum of your own practice”

P1 P3.5   Maura: “You would reflect more as well, on what your practices are, and why you do things, and it would give you a structure for that, a reflection”

P4 P1.2   Elen: “It’s really not about caseloads for me; it’s more about my own processes”

2. A place of learning and professional development

Many participants understand that clinical supervision will provide a space for them to increase their clinical knowledge and competence.

P1 P25.3   Maura:    “It would give me expectations as well, things that would be expected of me, so it would push me a little bit further, I think it would make me more aware, if I was answerable to or for my practices, I think it would make me look at things”

P3 P2.7   Mick:    “Ithink it would make you perform better to be honest  … I think it would make you more confident in your work and I think that will run through to your patients”

3. Constructive feedback

Feedback is seen as an intrinsic aspect of professional development and needs to incorporate both positive feedbacks with a mixture of constructive feedback.

P1 P1.2   Maura:    “I expect criticism to some degree, I don’t mean negative criticism, you expect if you want to go into this process,  you must expect there to be positive criticism”

P5 P5.2   Sean:    “You want someone to… if they were appalled by something, that they could put it in a constructive way, and equally that if they see something dangerous, they would say I’m really concerned about this, if there is a real risk there, you would want the person to be able to confront and deal with difficulty, not just say you are doing grand”

4.3.1.3 Clinical supervision is concerned with maintaining and ensuring the effectiveness of the supervisee everyday practice (Normative Function)

The Normative (managerial/organisational responsibility) function of clinical supervision endeavours to develop strategies, to manage the professional accountability, and quality issues in nursing.

1. Space for problem solving

Participants recognised the need to be able to discuss issues relating to their clinical practice within a structured environment.

P1 PI.2   Maura: “It’s good to have structure, I think, to discuss any issues that you might have… any areas that you feel you could do with more input on or further education with”

P4 P18.1    Elen: “If I’m at the end of my tether, and I don’t know what step to take next, then I will bring that in and I will ask, I need that, that is part of what I need”

2. Improvement in  practice through supportive space would have impact on patient care

Participants agreed that, through the medium of supervision patient care would be improved.

P3 P2.7   Mick: “I think it would make you perform better to be honest, I think it would make you more confident in your work and I think that will run through to your patients I think then as well”

P5 P4.2    Sean: “If the supervisor was really concerned, they would have an obligation to say something, and maybe talk to a line manager…I think that they would be protecting the client, by looking at, are you giving the patient, the best service”

3. Ensure standards are maintained

There was a sense from some participants, that clinical supervision would address the standard of care being delivered, and that there was an onus on the supervisor, to tackle any areas of concern in relation to professional practice

P4 P2.3   Elen: “It’s also for the supervisor, well it’s a way of seeing how someone is doing, if there are any concerns, we carry quite a heavy load, and I don’t just mean a case load because it’s the nature of this work”

P6 P1.4   Jane: “To improve the quality of care, and how the ward works and I suppose improve more the work practice or the working environment”

4.3.2 Theme 2: Factors which are necessary within the supervisory space

Theme two emphasized the need for an identified structured space, which would support staff’s own needs, in relation to the particular type of work they undertook. Further to this, the need for trust and confidentiality were stressed and a number of qualities attributed to the supervisor were highlighted.

4.3.2.1 Identified need for support for staff

There was a strong identification from all of the participants, with regards to the need for support for staff, which was seen as having a positive impact on the work environment and also on patient care. Participants acknowledged the effect of not having a structured space that supported their needs, had on their own mental health and professional practice

P1 P30.4     Maura:  “Colleagues, they don’t feel supported by anyone, and their work load is high, and they are frustrated… and I do think we give a lot of support to people, and we need support back”

P3 P11.1    Mick:  “Because we are always focusing on everyone else’s mental health, but you know we need to protect our own as well… who cares for the carers”

P4 P8.5     Elen:  “Supervision is more than just coming down and doing a session… it’s about being with a person, it’s really about being with someone for that time”

Not having access to supervision has been described by Mick as “being left to swim away on your own”

P3 P16.5    Mick:  “I don’t know is there, maybe, expectation that we are professionals and we get on with it”

P4 P11.3    Elen:  “You feel a bit lost really… so you carry on carrying the baggage with you and not getting anywhere at all”

P7 P13.6   Helen:  “It’s feeling isolated actually, so I am slightly isolated, despite my trying to get it, trying to talk about trying to get supervision”

Receiving supervision was identified as a positive experience which impact on staff and patients

P6 P20.4    Jane:  “Well, I think it will improve your working environment, which would obviously relieve your stress… that is all going to decrease you burn out levels”

P2 P6.2    Jim:  “Any level of support towards staff at all is seen as a good thing, rather than staff thinking they should have this kind of man up attitude, and just get on with it…”

P3 P2.7    Mick:  “You know that if you can get the bit of support, a bit of guidance, I think it would make you more confident in your work, and I think that will run through to your patients”

4.3.2.2   Safety within the space – confidentiality and trust

All of the participants identified that within the clinical supervision space, the areas of trust, safety, security and confidentiality where necessary conditions in order to encourage supervisees be more open and honest.

P1 P31.2     Maura: “You have to be able to be honest, you have to be able to be open and honest, because if you’re not then how can things change”

P3 P5.4    Mick:  “It’s important that you can bring into it, whatever you consider, what I consider a safe environment, that it’s non-judgemental”

P4 P4.3    Elen:  “You have to have trust, I think trust is a huge part”

P5 P4.4    Sean:  “There has to be a huge element of trust …it important that you are able to talk about where you are struggling and that takes confidence and that’s a risk”

4.3.2.3 Supervisor qualities

The participants identified a number of characteristics including the need to be skilled, which were necessary, to enhance the quality of the relationship with the clinical supervisor.

P1 P2.4    Maura:  “It would be good to have someone who was objective, I think that could come back to me, and be honest about me… to get an objective idea of how I am performing in my duties”

P3 P6.4    Mick:  “It would need to be someone that you trust, it needs to be someone that you respect I think…  I’d like to think that people have a bit of experience at it as well”

P5 P5.2    Sean:  “I guess they would need to be reliable, honest, confidential… someone that you can get on with, have a light moment but also be serious”

P7 P10.7    Helen:  “You would have to have some sort of experience of how to supervise clinical supervision, because it is quite a difficult art actually, it’s an art, skill, rather than art”

4.3.3 Theme 3: Factors that would impact on attendance at clinical supervision

All participants agreed, that a separation between clinical supervision and managerial supervision was fundamental, in order to maintain a trustful, safe, secure and safe space within the process.

4.3.3.1 Need for choice to attend rather than mandatory attendance

There were differing views, on whether clinical supervision was to be an established mandatory attendance, or whether giving people the choice to attend, would be more encouraging for people to attend. Clinical supervision as a mandatory training, within mental health nursing, was identified by five of the seven participants, with two participants identifying that people should be offered a choice to attend

P1 P14.2    Maura   “I would choose to take it, so I suppose I think probably a choice would be better, but I think if you make something mandatory, then it immediately changes the dynamics of a situation I think”

P4 P14.4    Elen   “I think it should be mandatory, but then are people going to… but it’s always been mandatory wherever I worked, but if you gave people a choice then we are back where we started”

P5 P11.1    Sean  “I think offering people a choice is important but the actual training is mandatory… but I think there needs to be supervision options rather than having  a one size fits all”

P6 P11.1    Jane  “Well I think it should be offered anyway, it’s not offered at all, and I do think it should be offered … but ultimately it probably should be mandatory for the improvement of the service”

4.3.3.2 Offer of both individual and/or group supervision

The opportunity to have a choice to attend either individual or group supervision was identified as necessary by many of the participants, in order to encourage attendance. The nature of being within a group supervision situation was perceived by some participants as a deterrent to authentic and open communication within the process.

P1 P12.2    Maura  “I just feel I would not be able to be honest in a group situation,, because they are my peers and I don’t really want to put myself down in their eyes, so I don’t think I would be brutally honest”

P2 P12.2    Jim   “My only concern about things being at a group level, is that you would run the risk of conflict of interest”

Conversely, the process of individual supervision allowed for more trust to develop, which would encourage the supervisee to express their thoughts and feelings more truthfully.

P4 P12.1    Elen   “I think individual, it’s really beneficial obviously because we all carry out own stuff”

P5 P13.2    Sean   “I think in a group most people would want to talk below the bar … I think choice of both is important, although groups can be very useful, they have limited use because of peoples defences”

However, the idea of a broader lens of a group supervision through which issues could be viewed and other view point allowed for, was seen as a positive experience by two of the participants

P3 P4.4    Mick   “It was interesting to discuss different things…. when you would go in, and feed back to the group, and people would often throw different ideas in…, it’s a broader thing, it’s better”

P4 P12.1    Elen   “I also like the many voices in a group, I like when you are hearing other people, obviously the more people that validate how you are feeling, or your emotions the stronger that word is, I suppose, I like both”

The option of choice for either individual or group was acknowledged by one participant

P6 P9.4    Jane… “I suppose either of them, but then again does it go back to the clinical supervisor, that if they are efficient in their facilitating skills, that they should be able to try and overcome that”

4.3.3.3 Supervision delivered by external supervisor as opposed to managerial supervisor

All participants’ felt that there was a need for clarity of the role of clinical supervision within the service. Some participants identified, that having  supervision from their line manager, would be a challenge for them in being open and honest, and there was a collective sense that they would be judged by their manager, and therefore supervision which was separate from their work environment was considered more realistic.

P1 P22.4    Maura   “I feel a member of management wouldn’t be a good idea, that you’ve opened up to a degree, and that you have maybe changed their perception of you, through your clinical supervision”

P3 P14.7    Mick   “I could see how people may feel, if it was a management thing, that if it was, that you were maybe being audited more than, I could see that being a negative side”

P5 P9.2    Sean   “it can be a barrier in reflecting your practice, if you are concerned that your manager might be aware of short comings, you might be concerned about promotional prospects, or the safety of your own job”

4.3.3.4 Necessity of supervisor to be experienced in mental health

There were varying views on whether the supervisor would come from a mental health nursing background or whether experience in working within the arena of mental health and from a different discipline was sufficient.

P1 P9.2     Maura   “They would have to have a mental health background, an understanding of the role of the job day to day”

P2 P12.2    Jim   “You would have somebody that would have a direct link to the environment and they would be able to empathise fully with you, and know what you would be talking about, that would be great”

P3 P8.3    Mick   “I would assume that they (mental health nurses )would have a better understanding of when I’m discussing issues, that they would have a feel or a gut for it, from experience”

However, for Jane and Helen having a supervisor that was experienced in providing supervision and understanding of mental health issues, was more conducive to a positive experience, that the supervisor being a mental health nurse.

P6 P6.6    Jane   “Maybe someone that definitely has experience of clinical supervision, maybe experience of mental health should be maybe a bonus… I wouldn’t say not necessarily a mental health nurse… if a person is qualified in it, and is proficient in it, I don’t know is it a necessary thing”

P7 P10.9    Helen   “I can’t see any problem with having supervision from another member or discipline, as long as it is someone who is experienced”

4.3.4 Theme 4: Challenges to providing clinical supervision

Theme four describes the factors, which participants identified would challenge the implementation of clinical supervision within their work environment. The sub themes that emerged within this main theme included both factors from an organisational perspective and also aspects in relation to the attitude towards clinical supervision from the staff themselves.

4.3.4.1   Organisational issues

All participants identified that there were organisational challenges which would need to be addressed in order to create a clearer pathway for the introduction of clinical supervision within their area of work.

1. Frequency and Timing of Supervision Sessions

The need for commitment to the frequency and timing of supervision sessions was widely commented on by all participants within the interviews. However, interviewees felt that due to staffing constraints that there would be challenges in ensuring that this would happen and meetings can, too easily, be cancelled or postponed.

P2 P17.7    Jim   “The main issues I feel is probably time ….the other place I worked, there were several times where clinical supervision had to be cancelled, because the person was sick who was facilitating it, the ward was too busy, there were times, uncontrollable circumstances did come into effect”

P1 P20.2    Maura    “Trying to sort out the ideal time…you never know what the day is going to bring …, it could be very busy, there could be people of sick, so if there are constraints it would be staffing levels and time I think”

Some participants felt that there was the need for, more focus on the importance of regular, supervision meetings whilst others recognised lack of time as a serious challenge. There was also widespread acknowledgement that effective supervision requires structured meetings that occur at regular intervals, on a pre-planned basis.

P3 P18.2    Mick   “Logistics would be a challenge like in the sense… is it in work time, is it in your day off, do you get time back”

P5 P 15.6    Sean   “I think people would look at time as being an issues… and I don’t think there would be a desire to have a flexible approach… it becomes a process or a procedure that is inflexible, and it doesn’t fit everybody”

Recommendations concerning the ideal frequency of meetings ranged from, monthly to every six or eight weeks, with one participant identifying that even an annual or bi annual check in, as a group, would be appreciated

P1 P11.5    Maura   “Maybe one a year or twice a year, as a group, touch base together”

P4 P20.4    Elen   “I think it depends on your case load really… but I think ideally fortnightly”

2. The value afforded to supervision

Reference to the value of supervision by management was made. Participants suggested that supervision is particularly important for staff, as the work can be stressful, and is often emotionally demanding. Many comments alluded to a general lack of appreciation of the importance of supervision, and pointed to the fact that supervision meetings could be deferred or cancelled at short notice.

P4 P20.2    Elen   “Supervision, if it is done properly, is paramount, it takes precedence over anything else… there should be cover for it”

P6 P16.1    Jane   “Staff need to be facilitated to join in clinical supervision…for clinical supervision to commence, management need to take it seriously as well”

The experience of where clinical supervision was valued and encouraged was experienced by one participant

P7 P5.6    Helen   “I worked in a climate where the MDT would have weekly clinical supervision, weekly supervision with a psychotherapist… people could go if they wanted to or not, they were encouraged to go, where you were encouraged to talk about what was going on”

3. Formal, Structured Supervision

A number of comments called for a more formal and structured approach to supervision. The importance of formal and structured supervision as a valuable and necessary component of professional practice and continuous professional development was recognised

P7 P15.4    Helen   “As a profession I do think we need to have special supervision, you do need to have a structure in place for mental health nurses, whether that be professional supervision or clinical”

There was widespread agreement that supervision, by its very definition, has to be properly organised, and that a structured format contributes towards its purpose being fully acknowledged and respected:

P1 P3.5    Maura   “To have something structured that you knew you would be attending or that you could go to once every couple of weeks”

P3 P19.6    Mick   “Structured, I think it would have to be structured, I think if you’re going to do it, it should be structured, from the point of view of, you do it every so often…once a month or every two months”

4.3.4.2   Staff own attitudes to clinical supervision

Whilst there were areas of commonality around understanding and perception of clinical supervision at an individual level, there were a variety of responses to the process of supervision itself.  There is an identified need for clarity with regards to the role and function of clinical supervision, to decrease the level of confusion.

1. There is a general sense of confusion among staff regarding understanding of CS

All interviewees identified differing understandings of the function of supervision

P3 P1.2    Mick   “It’s like an oversight in one sense of your practice, you know that you have someone, I view it as being a kind of supportive thing”

P5 P1.2    Sean   “It’s a space to reflect your practice, your clinical practice with an appropriate professional”

P7 P1.2    Helen  “I think clinical supervision in terms of your clinical work with your patients, would be separate from a supervision you would get from your line manager at work, which might be managerial supervision I think, because I think you need both”

Some participant felt that staff lacked experience, and understanding, and required education around the principles of clinical supervision.

P4 P10.3    Elen   “Well I think a lot of people don’t understand the principles of supervision, there needs to be education around it”

P6 P11.3    Jane   “Actually most staff have had no experience of it, and don’t know about it I suppose, and don’t know what the process is”

2. Fear of change

All participants identified with the challenges of introducing a new concept into the clinical setting which could create a sense of fear among staff.

P2 P15.2    Jim   “If you are then trying to introduce that, you are probably going to be met with, uncertainty from people…and change does have an effect on them, change has an effect on everybody….so that’s probably something, the idea of something different”

P4 P15.4    Elen   “Anything new is scary I suppose…  so anything new can be frightening”

P6 P16.1    Jane   “I suppose the challenge is that it is something new, staff might be suspicious of it, that would be a challenge”

3. Need for staff to be involved

Some staff identified that there is an organisational attitude of implementing change within the work place, without involving staff, which creates challenges for staff in terms of accepting these changes. Creating a culture of staff involvement in the process, would create a more positive response.

P3 P20.4    Mick   “If it was to come in, could it be brought in initially, on a trial kind of basis, get a bit of feedback from the people then with regards to how it is working, or where we need to improve or whatever”

P6 P4.2    Jane   “we don’t have the opportunity to be asked what we think… it happens all the time actually, that changes are just made, and there is no input from staff in the changes you know”

4. Challenging for staff

The challenge of introducing clinical supervision was acknowledged by all participants and a general sense of apprehension among staff was identified which would need to be addressed.

P3 P18.2    Mick  “There a good few people out there that think you know,  we don’t need it, it’s fine, we have done it this way for years, we are grand, we get on with it, get over yourself” or whatever, so that in itself, resistance would be a challenge”

P4 P3.4    Elen   “The word supervisor immediately gets alarm bells going for people, they start thinking, oh my God, the supervisor will see if I’m doing my job right”

P5 P15.6    Sean   “I think the staff would be largely resistant… I think that people would see it as a stick to beat them with”

However, despite the identified challenges at both an organisational and staff level, the general consensus among all participants was that the implementation of clinical supervision was a positive approach, which would be beneficial at patient, staffing, service and organisational levels.

P1 P22.2    Maura “I know personally I would take it, you know if it was offered”

P4 P24.1    Elen   “I would really love for people to understand what it feels like and what it is like to have it , there is nothing to be afraid of in fact it is to be really embraced”

P6 P12.4    Jane   “Well I know if it was offered I know I would jump at the chance”

4.4 Conclusion

This chapter described the qualitative findings from the seven semi-structured interviews that formed the basis of the study. Participants were very forthcoming about sharing their understanding on the subject as well as describing their own personal perceptions of supervision. Wide variations in the understanding of the function of supervision, as well as the challenges which may be met, in the implementation of clinical supervision are apparent. The findings identified a number of key challenges to providing effective supervision. A number of  developments that could be considered when addressing those challenges and enhance the individual experience of supervision within mental health nursing practice have been proposed. These findings are discussed in more detail in the next chapter.

Chapter 5  Discussion

5.1 Introduction

The following discussion will address the research findings. The extent to which the results explain the research objectives is considered as the findings are contextualised within the broader literature. The main objective of the study was to explore the understanding and perception of clinical supervision among a cohort of mental health nurses. Whilst their understanding and experiences varied and contrasted greatly, the first conclusion that can be ascertained is that the overall understanding of CS was that of supporting nurses and benefitting service users, with all participants fully committed to enabling CS become part of their mental health nurse practice.  The on-going issue of support and psychological safety was highlighted as fundamental which is reflective of similar studies (Buus and Gonge 2009).

The second conclusion that can be drawn from this study focuses on the importance of the supervisory relationship as a vehicle which can transport supervisees through restorative, normative and facilitative aspects of their work as discussed  by Proctor (1988). The third conclusion which was evidenced through the research was on an emerging need to recognise and separate managerial and clinical supervision strands to reflect and meet the various needs of mental health nurses practitioners at differing levels of experience.

Research is emerging on the need for separation of these areas of supervision within mental health nursing. The literature supports that it is preferable to separate clinical supervision and mentoring from line management due to the inherent power imbalances that exist within a line management relationship (Smith 2005). This is not always achievable within existing structures as there is diversity of organisational and management team structures in operation across the health service executive (HSE) and there is no single method of supervision which would adequately cover the  diverse nature and needs of mental health nurses working within these structures. The respondents in this study further highlighted the need to identify a range of effective supervision methods which can be selected in any combination in order to meet the needs of  the individual. There is no “one size fits all” which will suit all workers, disciplines, roles, managers and leaders and services … supervision types will have to be tailored to fit the organisation (Te Pou, 2013, p.6.). The overall emerging framework that reflects the understanding and  perception of clinical supervision of this cohort of mental health nurses is positive.

5.2 Current Levels of Access to Supervision

Clinical supervision is increasingly being recognized as a core professional competency within the mental health field (Brosan et al 2008). Supervision is also considered an essential component of modern effective health care systems (Kadushin, 2002) and training programs for mental health professionals generally(Milne et al 2011) and also  in relation to mental health nursing ( White and Winstanley 2011; Cruz et al 2013; Circenis et al 2015).

Despite the culture of evidence-based practices in mental health settings, the  practice of clinical supervision is trailing behind in its use of evidence-informed practices  (Schoenwald et al 2009).

Despite the indications from the research that signify a strong evidence base for the inclusion of clinical supervision within mental health practices, the majority of respondents within this study described limited access to structured supervision. Mental health nurses that undertook further professional education in the areas of psychotherapy and cognitive behaviour therapy, had greater opportunities to access supervision, however, mental health nurses who worked within an acute inpatient setting, reported that they do not have access to regular, scheduled supervision meetings. O’Neill (2004) specifies that of its very nature:

‘Professional  supervision is seen as a regular, structured process. The frequency of supervision will be  influenced by professional requirements, individual needs, the stage of development of the supervisee and the service expectations’ (2004, p. 62).

If supervision is to be used as a realistic and effective resource within any organisation, O’Neill recommends that supervision meetings should be conducted monthly or at least every six weeks.

Consequently, despite the opportunity to access supervision through more advanced practice the need for regular support structure among baseline nurses was highlighted within the research. The paucity of supervision meetings, suggests that supervision is not timetabled as a priority and that a casual and ad hoc approach underpins its access within mental health services.The importance of structured and formal supervision as part of professional practice and as a resource to equip practitioners to manage the on-going challenges of the workplace and the impact of the exposure to workplace stresses is widely supported in the literature (O’Neill, 2004; Morrison, 2005; Davys and Beddoe, 2010; Wonnacott, 2012). There are indications within the literature that supervision results in improved patient care outcomes (Bambling, King, Raue, Schweitzer, & Lambert, 2006; Bradshaw, Butterworth, & Mairs, 2007; Callahan, Almstrom, Swift, Borja, & Heath, 2009; Milne, Aylott, Fitzpatrick, & Ellis, 2008; Watkins, 2011) and that it acts as a quality assurance mechanism (Schoenwald et al 2009). Without supervision the quality control of mental health practice depends on the ability of practitioners to self-evaluate their competencies (Hansen et al 2006). However, self- evaluations prove to be difficult with beginning and lower skilled practitioners who are found to typically over-rate their competencies (Vallance 2005), which can have negative implications for patient outcomes and safety.

The demand shown within this research for more effective and formalised supervision reflects Hawkins and Shohet’s (2012) belief that effective supervision supports professionals to increase their individual and collective capacities to respond to the incontrovertible forces that continue to shape the context of the helping professions. Hawkins and Shohet’s (2012) identified these forces as: a greater demand for services, higher expectations of quality of service and fewer resources.

5.3 How Supervision is understood and provided

It has been acknowledged that the term clinical supervision itself is problematic as it is interpreted differently by different groups depending on the origin/historical use of the word, dynamic changes, relevance of the concept to different cultural groups, the language spoken and the meaning attached to this language (Walsh et al. 2003; Shanley & Stevenson 2006).

Bogo and McKnight (2008) strongly recommend the use of consistent terms in regards to supervision in order to facilitate communication about this area. The approach to clinical supervision practice varies within mental health settings. What emerged through the semi- structured interviews was the lack of a common understanding of the definition and function of supervision. Supervision is timetabled for some nurses who have undergone further education, and more advanced nurse practitioners have access to  regular, scheduled clinical supervision. However, for those nurses who work within an acute setting, there is a sense that  a much more casual approach has been adopted and access to  any form of  support is through the employee assistance programme (EAP). Within this research nurses identified that they had to seek out peer support,  in order to support them  through particular challenges associated with their place of work.

Dual roles were not considered desirable by most participants in this study. When CS and line management are provided by the same person, there is a risk of departmental issues taking priority over the supervisee’s learning needs. This is consistent with an allied health study by Dawson et al. (2012) which reported that supervisees’ expressed desire to better separate line management and CS. It appears that CS is more effective when provided by someone other than the supervisee’s manager. This is because such an arrangement promotes a confidential environment for the supervisee where they are better able to disclose information and discuss issues of concern without ‘guarding’. It is also likely that if CS and line management were provided by the same person, due to clinical priorities and competing work  demands, CS may be seen as secondary within the work context and hence pushed down the  list of priorities (Martin et al 2015).

Many of the respondents acknowledged that they could access support internally through their line manager. However, it emerged during the interviews that 100% of the respondents found this concept challenging as there was a sense that managers  lacked the skills or discernment to provide effective supervision for them. All of the participants with previous experience of managerial CS felt that they would not wish to have CS with their direct on- line manager, who would be based with them within their area of work. They qualified this further, by clarifying that this overlap and duality of roles leads to confusion within the work environment. This is consistent with research findings (Te pou 2011). There has been much debate in the literature regarding the effectiveness of clinical supervision provided by a line manager (Spence et al. 2001; Sweeney et al. 2001a,b,c; Landmark et al. 2003; Abbott et al. 2006; Herkt & Hocking 2007; Kleiser & Cox 2008). A critical literature review on the integration of clinical and managerial supervision by Kleiser and Cox (2008) found that some authors acknowledge that managers can operate effectively as supervisors. However, when line management and clinical supervision is provided by the same person, evidence suggests that supervision time is frequently taken up in discussion of administrative issues, rather than clinical matters (Spence et al. 2001; Kleiser & Cox 2008). In some instances, administrative supervision/line management is linked to performance evaluation of the employee.

When this happens, there are a range of ethical and practical issues surrounding this combination of roles  (Spence et al. 2001; Herkt & Hocking 2007).Where possible, clinical  or professional supervision should be given by someone who is not the supervisee’s manager to avoid conflicts of interest and allow for a completely open reflective process for the  supervisee – without concern about judgement or reprimand from management. There was a strong sense from the respondents in this research, that clinical supervision provided by their line manager would be viewed as a  administrative instrument to manage staff and that this in itself would challenge staff to be open and transparent about self-reporting concerns regarding their clinical practice.

5.4 Purpose and Value of Supervision

The overall aim of clinical supervision should be to support the provision of services in accordance with the organisation’s responsibilities and accountable, professional standards.

The secondary aim should be the well-being and job satisfaction of all employees which communicates the employer’s ‘duty of care’ for those working in difficult and challenging roles (Carpenter et al, 2012). As early as 1995, Ash recognised that whilst supervision is widely accepted as an essential feature of practice in the caring professions, it often suffers from lack of resources and frequently happens more in the intent than in the reality. Despite written manuals, guidelines and even contracts, supervision is often sacrificed for more ‘pressing needs’ that require urgent action and an immediate response from managers (ibid).

The confusion and conjecture about clinical supervision for nurses resonates across most healthcare disciplines (Farnan et al., 2012; MacDonald & Ellis, 2012; Spence et al 2001).

Therefore, there is a strong argument to advocate that  if clinical supervision is to achieve patient-centred care and innovation of practice; it first needs to be legitimised as real work.

This will involve genuine support from nurses, management and healthcare organisations.

The research signalled a clear demand for a common understanding of the purpose and value of supervision, amongst all employees’ and across mental health services.

The importance of adopting a suitable model of supervision that would facilitate the broad remit of the work of all mental health practitioners whether in a frontline role or those in therapy roles , accompanied by an agreed set of practice principles and supported by an appropriate training and implementation strategy was clearly identified in the interviews.

Having such a strategy would ensure that the practice of supervision is effectively and consistently executed in all mental health settings which would further corroborate the argument for sufficient resources to do so.

5.5 Supervision as a Function of Professional Practice

The recognition of supervision as a core element of professional practice is widely promoted in the literature and was highlighted by the seven interviewees in this study. In many professions, supervision is a mandatory activity that is regarded as fundamental to ensuring the development and maintenance of professional, reflective and ethical practice. However, in many others, the concept is less common place, often misunderstood and not necessarily viewed as a ‘requirement to practice’ as there is no legal imperative in place to provide it (Hawkins and Shohet, 2012). In part the complexity and confusion within the literature is generated by the diverse expectations and outcomes of clinical supervision. Clinical supervision is considered by many as a means of supporting and educating nurses and has been employed in attempts to maintain changes in practice established by educational interventions (Heaven et al 2006; Mannix et al., 2006), to ensure staff and patient safety (Turner et al., 2011), to improve patient satisfaction outcomes (White & Winstanley, 2010), to increase professional dialogue (Kilcullen, 2007; White & Winstanley, 2010), to decrease and/stress (Hyrkäs et al ; Severinsson, 2003; Wallbank & Hatton, 2011) and to provide formal support structures and facilitate reflective practice (Botti et al., 2006; Turner et al., 2007; Watts et al 2010).

Noble and Irwin (2009) further  underline the essential role that organisations play in promoting effective supervision practice and warn that an irregular, unpredictable and casual commitment to it can undermine its use and its value. As mental health nurses are being compelled to provide extended services within ever reducing resources,  they assert that the lost opportunity to access new knowledge and critically reflect on the issues that practitioners are facing in their daily work may be at the expense of professional practice and development. Similar responses were expressed by the interviewees in this study.

Promoting the value of effective supervision, Juby and Scannapieco (2007) comment on the need for ‘bearable’ and ‘manageable’ jobs and observed that workers who had supportive supervisors tended to have positive attitudes to their work regardless of workload or other adverse working conditions.

A body of research that links organisation variables such as quality of supervision to improved outcomes for ‘consumers’ or those accessing the services is now emerging (Poertner, 2008). Further evidence-based research in this area will support mental health practitioners to be more confident about arguing that the delivery of effective supervision not only benefits the supervisee but also has a correlating positive impact on the clients that access these services. As Mor Barak et al (2009, p.25) observed:

‘Accumulating research on supervision indicates that the various dimensions of supervision may have protective,  proactive or preventative roles in ensuring a positive work environment that can contribute  to worker effectiveness and potentially to quality service delivery’.

5.6 The Challenges to Providing Supervision in mental health settings

Four key challenges in providing supervision within mental health services were identified through the research:

(1) The frequency and timing of supervision sessions;

Qualitative studies report that attendance at clinical supervision was limited due to nurse unwillingness to attend clinical  supervision outside of their shift times (Buus et al., 2011; Chilvers & Ramsey, 2009; Cross,  Moore, & Ockerby, 2010; Kenny & Allenby, 2013). Buus et al. (2011) suggest that the nurses’ recreational time off was more valued than clinical supervision. To this point it could be argued that attendance at clinical supervision while off duty equates to a boundary  violation as defined by the Australian Nursing and Midwifery Council (ANMC) (2010). The expectation for nurses to attend in their own time could in fact be interpreted as creating a moral dilemma. To address this it is necessary that implementation takes into account the needs of nurses working on rotating 24-hour rosters.

This is not impossible. White and Winstanley (2009) found that rosters could be negotiated.

This was possible where the person implementing clinical supervision had influence over the roster or with support from managers. Commitment aspects of the debate are related to the lack-of-time argument. Active support from management or those administering rosters is necessary to allow dedicated time within work hours to support clinical supervision.

(2) The value afforded to clinical supervision;

Lack of time and busy workloads are consistently noted across specialities and across disciplines as a barrier to implementing and maintaining clinical supervision (Chilvers & Ramsey, 2009; Cleary & Freeman, 2005;  White & Winstanley 2009). The value of having time dedicated to discuss clinical work in a reflective forum is one of the benefits of clinical supervision (Cross et al., 2010). Edwards et al. (2005) explored the factors that impact on the effectiveness of clinical supervision. To be effective they recommend clinical supervision be held monthly for at least one hour. At a managerial and individual level time needs to be allocated to allow such forums to occur. This was highlighted by nurses within this research in that workloads and time pressure were deemed as strong barriers to attendance at supervision. However, there was a sense that if a culture of transparency and commitment to supporting staff through clinical supervision was evidenced this would negate a number of the speculations around the implementation of clinical supervision.

(3) Supervision Skills and the Supervision Relationship

The importance of the supervision relationship was highlighted as crucial by all of the research participants. It was identified that allowing for time to develop trust within the relationship was crucial and that is would lead to supervisees feeling accepted personally and professionally. The sense of acceptance by the supervisor would facilitate further growth and confidence-building which would increase the ability to learn, unlearn and question practice.

The supervisory relationship is covered extensively in the literature (Kavanagh et al, 2003; Cearley, 2004; Stalker et al, 2007; Jenkinson, 2009;). Mor Barak et al (2009) propose that the most important implication from their study is that organisations will benefit from generating policies and investing resources in nurturing the supervisor / supervisee relationship and creating an organisational culture that promotes the value of such relationships. The authors recommend that organisations stimulate the mandatory nature of  supervision in their policies and indicate the expected frequency of supervision meetings.

Similar recommendations were made by research participants to improve supervision practice within mental health services. Organisations also need to evaluate internal levels of satisfaction with the structures that are in place, particularly in relation to the supervisor / supervisee relationship to provide a feedback mechanism to alert the organisation about the training needs of supervisors as well as inform individual supervisors about specific areas in which they could improve their skills (Mor Barak et al, 2009).

The need for training to improve supervision practice and up-skill supervisors, to develop their capacity to provide more valuable supervision, was strongly identified in the research.

Because of the complexities involved in effective supervision practice and the fact that it requires an additional knowledge base, competencies, capabilities and capacities from those acquired in one’s original professional training – all supervisors need a period of formal training and development (Hawkins and Shohet, 2012). Munro (2011) cautions that investment and training is required to equip supervisors with the required skills to support individual workers and provide high quality supervision. Falender et al (2004) acknowledge that supervision is a domain of professional practice for which formal training and professional standards have been largely neglected. They advocate a curricular approach to supervision training that translates competencies to measurable criteria and consider ‘supervision of the supervisor’ as essential. Rapisarda et al (2011) also stress the importance of supervising the supervisor because of its significance in contributing  to the quality of the supervisory relationship. Hawkins and Shohet emulate this concept:

‘The first prerequisite for being a good supervisor is to be able to actively arrange good supervision for oneself’

(2012, p. 51). Two of the respondents within this research acknowledge their concern that there was transparency related to supervision practices for those providing clinical supervision. They identified that this would create a greater sense of safety in relation to the skills and competency of the clinical supervisor.

(4)  Resistances to clinical supervision.

The nature of nursing work remains task and routine oriented (Scott & Pollock 2008; Watts et al., 2010). In relation to clinical supervision, within this research nurses describe feeling that clinical supervision was from an organisational and managerial perspective. This identification with  low priority and attendance at supervision as taking from time on the ward was also noted by  (2005) in that it would be seen as ‘skiving’. Within the literature  a number of studies  described a sense of nurses’ attitudes to clinical supervision as ambivalent (Brunero & Stein- Parbury, 2008; Kenny & Allenby, 2013) , nurses perceive that attendance at clinical supervision may be construed as not coping or linked to performance management concerns (Cleary & Freeman, 2005; Kilcullen, 2007; White & Winstanley, 2009).

Conversely within this research there was 100% positive response to undertaking and commitment to clinical supervision and mandatory attendance was indicated by a greater proportion of the respondents.

Many participants identified that staff within their areas of work actively resisted the concept of CS being introduced. Some participants had experienced receiving clinical supervision as a mandatory practice within their working environment, however, this was reported only by those who had either trained or worked abroad. They were quite vocal about the lack of support that they have individually felt since commencing practice within the Irish health system through paucity of access to clinical supervision.

The literature highlights a number of reasons supervisee may be resistive to supervision including, Liddle (1986) whom described resistance  as maladaptive coping with anxiety, which interferes with the supervisee’s learning processes which is not necessarily purposely motivated by uncooperative supervisees, but can be determined as the consequence of coping gone astray. Addressing clinical supervision from a nursing perspective, Bond and Holland (1998) argue that resistance to supervision practices should be understood as counter-productive defences against feeling anxiety in difficult situations.

Resistance could be present for a number of reasons including a perceived threat, a need to individuate from the supervisor, disagreements about goals, decreased trust in the supervisor, and a high reactance level (Bernard & Goodyear, 2009). The developmental level of the supervisee contributes to different types of resistance; for example, supervisees who are advanced are more likely to individuate from their supervisors, resulting in conflicts of individuation more often than novice supervisees. Supervisees’ shame and anxiety influences conflict, and the supervision process may elicit shame and anxiety, resulting in withdrawal, avoidance, or attack on self or others (Bernard & Goodyear, 2009)

The context of where the supervision was undertaken, within the work environment was identified as of greater importance by the participants than on the particular model of supervision utilised. There was the understanding that supervision sessions could be cancelled or interrupted due to the demands of the service. This reinforced the tenuous nature of the supervision and the powerlessness that was felt within the organisational context.

There was a sense of being unable to address any areas of conflict with colleagues within the team for fear of being judged by the supervisor. For the nurses within this study there was a great sense of being bound by the legislation which underpins their nursing practice which some participants identifying with a sense of being misunderstood and isolated on occasions where there was a legal duty of care around a mental health issue. A number of the participants identified that in order to address these issues it was of fundamental important that the supervisor was able to identify and had experience in working within a mental health environment and where possible had a background in mental health nursing as this would provide them with a more meaningful insight into the challenge and moral dilemmas faced by respondents within this study.

Limitations and strengths of the study

Despite generating new knowledge about important issues pertinent to CS within mental health nursing, there are some limitations to this research. This research was conducted with seven participants, from one geographical location in a rural mental health setting. While this may be considered as a limitation as the findings cannot be generalised to the broader population of mental health nursing, they nevertheless provide some useful insight into CS issues that require on-going exploration and research. While the qualitative arm of the study explored the quality of CS from a supervisee’s perspective, it did not explore the supervisor’s perspective. Further studies are required to explore this. Whilst this study provides rich information about CS in mental health nursing, it does not provide a multidisciplinary perspective. Further research is required especially within multidisciplinary professions to investigate what factors make CS effective.

On the positive side, the methodology used proved effective. It enabled the identification and collation of a large volume of raw data, its conversion from individually identified factors into clusters of related significance and finally into core conceptual meanings. Credibility was enhanced as data eligibility demanded that volume and quality thresholds be attained.

The process ensured that findings could literally only support what was adequately found.

When participant discussion was interpreted, direct quotes were used to illustrate typical ideas or key points and this further embedded the requirement for accuracy and relevance.

Credibility was further reinforced through the systematic application of methodology which was tracked through the maintenance of a comprehensive documentation process. 

Conclusion

Health professionals such as mental health nurses practising in acute mental health settings and as advance nursing roles such as CBT therapists, and psychotherapists rely on CS for professional support and guidance. While policies and guidelines exist in other organisations such as social work regarding minimum CS requirements, there is a paucity of  research within the context of mental health nursing from an Irish perspective little was known about how CS was actually understood and perceived. This study explored the understanding and perception of clinical supervision from the view point of mental health nurses both from an advanced practitioner to a nurses practising within an acute mental health setting.

The findings from this study contribute to the growing evidence base for CS within professional practice and in particular the practice of mental health nursing.  The findings from this study indicate that a number of factors were perceived to be associated with high quality CS. The supervisory relationship appeared to be associated with perceptions of higher quality of CS received. Supporting previous literature findings, the findings from this study also highlight a general sense of confusion regarding  supervision and the associated terminology. Lastly, dual roles, where someone received CS and line management from the same person, were not considered desirable. A number of enablers of and barriers to high quality CS have also been identified. As CS gains prominence as part of organisational and professional governance, it is imperative that implementing best practice CS is underpinned by current best evidence regarding “what works” in practice contexts. The findings from this study provide important lessons for successful and sustainable CS implementation in practice contexts.

Recommendations

Diverse local contextual factors suggest a common understanding and uniform implementation is not possible. For clinical supervision to be successfully established in practice, programmes will need to be locally negotiated so that they meet the needs of the staff involved. An appreciation of local and contextual factors is consistent with the organisational change and innovation literature that to take into consideration the complexity of the local situation (Grol et l 2007). Alongside the fairly limited body of quantitative evidence there is a large body of qualitative research. It is here that many insights about the benefits and transformational aspects of clinical supervision can be explored. The benefits explored are practice change and innovation, new skills/confidence that expand health professionals’ scope of practice and the generation of shared understandings of care.

Resistance and ambivalence from nurses that perpetuate old-fashioned interpretations of nursing practice need to be challenged. Research needs to explore clinical supervision as a potentially professionally enriching interaction with others that may result in appropriate, safe patient care that is provided in a satisfying work environment. If these result are achievable then research needs to further explore the mechanisms by which these changes are achieved, or not, in which contexts.

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