Essay: Effect of Clinical Supervision Program for Head Nurses on Quality Nursing Care

1. Introduction
Position of head Nurses is a vital at each unit and one of the most difficult, demanding, and challenging jobs in any organization, where assess, evaluate the work performance of nurses, review completed medical forms to assess record keeping abilities and inspect work areas for organization. So most of his/her functions are concerned with supervision, development of moral, interest, and increase high quality nursing care in his or her unit (Morsy, 2014).
Nursing supervision is a process designed to enhance the learning, and performance of another with the direct intention of enhancing the supervisee’s ability to deliver the highest standard of care. Many organizations feel that the most future task of them is clinical supervision (Edwards et al., 2006).
Clinical supervision is becoming standard practice for health professionals, and has been considered to be an important component of comprehensive clinical governance (Bernard & Goodyear, 2009). Clinical supervision is, ‘a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations’ (Victorian Healthcare Assocation, 2010).
Benefits of clinical supervision have a range for clinicians and the organization. Which include: availability of support for supervisees, a forum to discuss clinical issues, promotion of standardized performance of core skills across the organization or field, improvement or attainment of complex clinical skills, increased job satisfaction, self confidence, improved communication amongst staff nurses, professional development reduced administration costs, improved service delivery through the use of evaluation systems (Senediak, 2012).
Clinical supervision has been promoted as a key clinical governance component to ensure the provision of and accountability for the quality of care provided to patient and to minimize the risk of adverse outcome for patient. Quality of care is one of the most important goals of a health service, and should be regularly evaluated. Improving the quality of care in practice is a challenge for both manager and staff (Victorian Health Association, 2010).
Quality nursing care as a level of experience in nursing practice, knowledge, skills, and competence to provide care for patient without error. Quality nursing care is the degree of excellence in nursing care provided for patients that meets the patient’s spiritual, mental, social, physical environmental needs and multidimensional, complex therapeutic effective care which occurs when physical, psychology, any extra needs of patients are met (Livni et al.,2012).
Clinical supervision provides nurses with an opportunity to improve quality of patient care in particular for a given patient and in relation to maintaining standards of care. In addition, CS provides an avenue for nurses to demonstrate active support for each other as professional colleagues, and providing reassurance and validation (Health Workforce Australia, 2011).
Significance of the study: Effective clinical supervision may increase nurses’ perceptions of organizational support and improve their commitment to an organization’s vision and goals. Clinical supervision is correlated with perceived nurses’ effectiveness, increase critical thinking, pays attention to task assistance, increase social, emotional support and reduce staff turnover. Clinical supervision is helping nurses to avoid medical errors and job-related stress, enhance well-being and improves clinical performance which in turn, leads to improved quality patient care, decision making abilities of nurses and patient safety.
2. Aim of the study: To examine the effect of clinical supervision program for head nurses on quality nursing care.
3. Study hypothesis: Applying clinical supervision program for head nurses can improve quality of nursing care
4. Subjects and Methods:
4.1 Design: A’Quasi-experimental design was used in the study.
4.2 Setting: This study was conducted at all departments of Kafer EL-Sheikh General Hospital, which consists of one building (with bed capacity 357 beds).
4.3 Subjects: Subjects of this study included two groups:
Group (1): All head nurses working in all departments at the time of data collection (69 head nurses).
Group (2): Compromise (192 staff nurse) according to calculation of sample size, and work relation with head nurses in the previously mentioned setting.
4.4 Tools of data collection: – The data will be collected by using three tools:-
4.4.1 Tool (1): Clinical supervision knowledge questionnaire included two parts:
The first part: Personal characteristics of head nurses : as age, marital status, years of experience, educational qualification, and department.
The second part: Clinical supervision knowledge questionnaire: developed by the researchers based on review of related literature (Helen & Douglas House, (2014), Brunero & Stein Parbury, (2013), Cruz ,( 2012), Abou Hashish, (2010), Ballon & Waller-Vintar,( 2008), Hyrkas ,( 2003), Hyrkas ,( 2002) and Winstanley & White , (2003).The questionnaire aimed to identify head nurses level of knowledge regarding clinical supervision. Consisted of 52 questions related to the concept of clinical supervision, role of clinical supervisor in clinical area, essential skills for clinical supervisor, and clinical supervision process and models. The questions classified into (30) true and false questions , (11)Multiple choice questions, (11) Matching question . The questions were scored by one for each correct answer and zero for incorrect answer. Low clinical supervision knowledge (<59, 9), Moderate (%60 – 74.9%), High Clinical supervision knowledge (75% – 100 %). Low scoring means they have inadequate knowledge and High& moderate scoring means head nurses have adequate knowledge (morsy, 2014).
4.4.2 Tool (2): Manchester Clinical Supervision Scale (MCSS) Consisted of two parts:
Part 1: Personal characteristics of staff nurses: as age, marital status, years of experience, educational qualification, and department.
Part 2: Manchester Clinical Supervision Scale (MCSS): developed by Winstanley (2000), and aimed to measure effectiveness of the supervision as perceived by staff nurses. It consisted of 36 items categorized in 7 subscales namely; trust/rapport (7items), supervisor advise/ support (6 items), improved care/ skills (7items),importance/value of clinical supervision (6 items), finding time (4 items), reflection (3 items) and personal issues (3 items).
Responses were rated on 5- point likert scale ranging from (5) strongly agree to (1) strongly disagree. The percentages of mean score classified as a following: <49.9 = Low level of effectiveness of the clinical supervision. From 50 – 74.9 = Moderate level of effectiveness of the clinical supervision. From 75 – 100 = High level of effectiveness of the clinical supervision (Abou Hashish, 2010). 4.4.3 Tool III: Quality of Nursing Care observation check list (QNCO) An observational check list was developed by the researchers based on review of related literature (Abd EL Aziz, (2011), Fauzy, (2013), and Mohamed, (2009), used to assess the quality of care in the study units. The observational check list consisted of 160 items It included seven main dimensions namely: Practitioner nursing qualities (staff characteristics including: 13 items), task-centered activities of nursing including (physical, educational and supportive-initiative activities: 86 items ), human-centered activities of nursing including (respect, caring, advocacy and encouragement: 18 items), preconditions for care (4 items), progress of nursing/patient care process (8 items), and the care environment including (physical, psychological and social needs environment: 17 items), evaluation of achievement of nursing care objectives including (Protecting patient from accident and injury and evaluation of patient response to therapy:14 items) . Observation check list scored on the basis of done (yes complete and yes incomplete), not done, and not applicable for each activity. Score (3) for yes complete, (2) for yes incomplete, one for not done and a score zero for not applicable steps. Scoring represent varying levels of quality nursing care; Low = 49.9 %, Moderate = 50 -74.9 % and High = > 75 % (Fauzy, 2013).
4.5 Methods of data collection:-
4.5.1 Ethical consideration:-Before commencing the study, ethical approval was granted from the research ethics’ committee in which the study took place. The researchers ensured that the correct procedures were undertaken concerning informed consent, autonomy, anonymity and maintenance of the subjects of confidentiality.
4.5.2 Official permission to conduct the study was obtained from the manager of hospital and administrator of training department at Kafer EL-Sheikh General Hospital.
4.5.3 Tools of data collection (tool 1 & 2) were translated into Arabic, and all three tools were tested for its content validity and relevance by a jury consisted of five professors from nursing administration departments from Tanta and Damanhur University and accordingly the necessary modification was done.
4.5.4 The reliability for the tools were done using alpha coefficient to measure the internal Consistency reliability of the three tools; it was (.77) for Clinical supervision knowledge questionnaire, (.77) for (MCSS) and (.89) for (QNCO).
4.5.5 A pilot study was carried out on (7) head nurses and (19)staff nurses from different departments in Kafer EL-Sheikh General Hospital, to evaluate the clarity and applicability of the tools and necessary modifications were done based on their responses and excluded from the total sample.
4.5.6 Informed consent for participation in the study was secured from the entire study sample. Participation in the research is voluntary. Each participant may decide to stop completing the study and withdraw at any time without consequence.
4.5.7 Designed an educational program: which include objectives of the training, Definition, purposes, and importance, benefits, misconception of clinical supervision, elements, core principles, functions, factors influencing, methods and modes, enabling factors for effective clinical supervision, barriers to sustaining clinical supervision, important characteristics of clinical supervisor, role of nurse managers in clinical supervision. Essential skills for head nurses as a clinical supervisor: Communication, coaching, delegation, motivation, problem solving &decision-making and conflict resolution, stress management, and time management. Process, models of clinical supervision, rights and responsibilities in supervisor- supervisee relationship. Ethics, legal issues and confidentiality in clinical supervision. Documentation, supervision contracts and plan.
4.5.8 Implementation of the educational program: The data was collected by the researchers and the questionnaire sheets of tool (1) and tool (2) were distributed to study subjects as (pre test) before starting the program at morning shift by the researchers then post immediately and 3 month after the program. The time needed by each study nurse to complete each sheet ranged from 25-30 minutes. .
4.5.9 As regard to the third tool (continuous observation sheet) , conducted for staff nurses (n=192).The observation done six working days per two weeks, 2hours per morning shift for each nurse to collect the necessary data concerning quality of nursing care using the developed (QNCS) pre and post program.
4.5.10 The program was conducted in the room conferences for all head nurses (69) working in all departments of Kafer EL-Sheikh General Hospital. The time for program was amount to (36) hours implemented for 6 weeks for three groups of head nurses divided into six sessions per two working weeks for each group of head nurses and each session was had 2hours.
4.5.11 Different teaching and learning methods were used during the sessions which included; interactive lecture, group discussion, demonstration, brain storming, work in small groups.
4.5.12 Actual field work started at the beginning of March 2015 and was completed at the end of Augusts 2015.
4.5.13 Statistical design: The collected data were organized, tabulated and statistically analyzed using SPSS software (Statistical Package for the Social Sciences, version 13, SPSS Inc. Chicago, IL, USA. For quantitative data, the range, mean and standard deviation were calculated. For qualitative data, comparison between two groups and more was done using Chi-square test (2). For comparison between means of two groups of parametric data of independent samples, student t-test was used. For comparison between means of two groups of non-parametric data of independent samples, Z value of Mann-Whitney test was used. Correlation between variables was evaluated using Pearson’s correlation coefficient (r). Significance was adopted at p<0.05 for interpretation of results of tests of significance.
5. Results:
Table (1) Represents demographic characteristics of study subjects (nurses &head nurses). According to the table, more than half of the head nurses (52.2%) were in the age group (30- <40) years with mean score (39.7”10.43) and (36.3%) of them had experience in nursing from (10- < 20) years, with mean score (18.59”11.62). Concerning education level, more than half of them (60.9%) was having Bachelor degree and most of them were married (89.9%).
While the high percent of nurses (76.0%) were in the age group (20- <30) years with mean score (28.88”6.9) and were having (<10) years of experience in nursing. Concerning education level (37.0%) was having Diploma Technical Health institution. While (36.5%) were having Diploma of Secondary Technical Nursing School, (26.6%) were having Bachelor degree and most of them were married (90.1%). Regarding Working shift, (72.9%) of nurses worked in all shifts and (19.3%) of nurses worked in morning shift. For the type of supervision received from the supervisor, majority (96.9%) of nurses were having both one to – one and group supervision and all of nurses received their supervision during working time. As regards, length of supervision per working shift, (48.4%) of nurses received supervision less than 15minutes and (32.8%) of nurses received supervision from 15 to 30 minutes. Table 1: Demographic Characteristic of study subjects (nurses &head nurses) Head nurses (69) Staff nurses (192) Age 20- 30- 40-50 >50
7
36
6-
20
10.1
52.2
10.2
27.5
146
34
7
5
76.0
17.8
3.6
2.6
Range: 22-59
M(SD):: 39.7”10.43 Range: 21-56
M(SD):28.88” 6.9
Years of experience
<10
10-
20-
30-40
17
25
7
20
24.6
36.3
8.7
30.4
140
36
10
6
72.9
18.7
5.2
3.2
Range: 3-40
M(SD): :18.59”11.62 Range: 3-40
M(SD)::10.59”8.62
Level of education
*Bachelor
**Dip. THI
***Dip. STNS
42
–
27
60.9
–
39.1 51
71
70 26.5
37.0
36.5
Marital status
single
Married
divorced
62
7
–
89.9
10.1
–
17
173
2
8.9
90.1
1.0
Working Shift
morning
night
evening
All
–
–
–
–
–
–
–
–
37
4
11
140
19.3
2.1
5.7
72.9
Type of supervision received from the supervisor
One ‘ to one basis
Group basis
Both one ‘to one and group –
–
– –
–
– 4
2
186 2.1
1.0
96.9
Time of receiving supervision
During nursing procedure
After nursing procedure –
– –
– 192
0 100
0.0
Length of supervision received)
<15 min 15-min 30-min 45-60min – – – – – – – – 93 63 17 19 48.4 32.8 8.9 9.9 Head nurses Nurses **Diploma Technical Health institution- ***Diploma of Secondary Technical Nursing Figure 1: Level of nurses’ Perception regarding Clinical Supervision pre, immediately post and after three moth post program (N=192). Figure (1) show that statistical significant differences in total of nurses’ perception of clinical supervision at the three times of the program (pre, immediately post and after three months of the program implementation). The total percent score of nurses’ perception of clinical supervision as general was indicated Moderate level of the nurses’ perception of clinical supervision pre the program which significantly increased immediately post and after three months of the program implementing reflecting that High level of nurses’ perception of clinical supervision. Figure 2: Level of Knowledge of head nurses’ regarding clinical supervision pre, immediately post and after three month post program (n=69). Figure (2): shows high statistical significant improvement in Level of knowledge of head nurses’ regarding of clinical supervision at the three times of the program. (87%) of head nurses were low level of knowledge pre program and significant improved to (95.6% and 94.2%) of them were High immediately post and after three month respectively. . . Figure 3: Level of Quality of Nursing Care as Observed pre, immediately post and after three month post program (N=192). Figure (3): show that statistical significant differences in total quality of nursing care as observed in all departments of study setting at the three times of the program (pre, immediately post and after three months of the program implementation. Total quality of nursing care was (68%) reflected Moderate level of quality of nursing care pre the program which significantly increased immediately implementing post and after three months to (75% and 66%) reflecting that High level of quality of nursing care respectively. Table (2): Correlation between Knowledge of head nurses’ regarding Clinical supervision, nurses’ perception of clinical supervision and quality of nursing care as observed. Clinical Supervision Supervision knowledge Variables three months post Program immediately post Program pre Program three months post Program immediately post Program pre Program r P r P r p r p r p r P 0.028 0.819 0.01 0.928 0.213 0.081 Clinical supervision 0.044 0.548 0.076 0. 298 0.069 0.234 0.023 0.855 0.032 0. 794 -0.069 0.629 Quality of nursing care Positive correlation r>0 Negative correlation r<0
Table (2): Represents Positive correlation between knowledge of head nurses’ regarding clinical supervision and nurses’ perception of clinical supervision, as well as quality of nursing care pre, immediately post and after three months of the program implementation. In addition, negative correlation between Knowledge of head nurses’ regarding clinical supervision and quality of nursing care as observed pre the program while there was positive correlation immediately post and after three months of the program implementation. This means improving head nurses knowledge reflected on improving nurses’ perception of clinical supervision and quality of nursing care, they provided to their patients.
6. Discussion:
Supervision is vital for personal and professional development in work place. Clinical supervision in the workplace was introduced as a way of using reflective practice and shared experiences as a part of continuing professional development (CPD). Moreover, clinical supervision is widely discussed as a mean of helping nurses to avoid medical errors and job-related stress, enhance well-being and improves clinical performance which In turn, lead to improved quality nursing care (Russell, 2013).
Finding of the present study indicated that there are statistical significant differences in total of nurses’ perception of clinical supervision at the three times of the program. The total percent score of nurses’ perception of clinical supervision as general was indicated Moderate level of the nurses’ perception of clinical supervision pre the program which significantly increased immediately post and after three months of the program. This could be attributed to the changes in nurses’ perceptions of the effectiveness of clinical supervision of their head nurses post implementing the education program. So, head nurses learned and gained knowledge from all topics of clinical supervision and its elements as well as the essential skills and how to implement the clinical supervision for nurses, this resulted in positive perception of nurses toward the effectiveness of clinical supervision provided by their direct clinical supervisors.
The effective clinical supervision may increase nurses’ perceptions of organizational support and improve their commitment to an organization’s vision and goals. It is one way for a provider to fulfill their duty of care to staff. Importantly, clinical supervision has been linked to good clinical governance, by helping to support quality improvement, managing risks, and by increasing accountability (Registration under the Health and Social Care Act, 2013).
In the same line, (Cruz, 2011), who conduct a study on Clinical supervision in nursing: effective pathway to quality and reported that statistically significant differences of opinion in all dimensions of the Portuguese version of the Manchester Clinical Supervision Scale with the exception of the sub scale ‘finding time’ .
This also was consistent with Edward et, al., (2006) who indicated that, training on clinical supervision could result in changes in the attitudes, values, behaviors of clinical supervisor as well as the supervisees’ perception of their managers. The provision of training program for clinical supervision for nurse-managers has been effective in influencing the attitude of both nurse managers and nurses and results in clinical supervisors’ understanding of clinical supervision, its importance and how it occurred (Hancox et,al., 2004).
This result is consistent with the findings of Cheater and Hale (2000) which revealed significant positive views of practice nurses of the clinical supervision provided by their clinical supervisor after implementing education program for clinical supervision.
Finding of the present study indicated that high statistical significant improvement in Level of knowledge of head nurses’ regarding of clinical supervision at the three times of the program. Head nurses were low level of knowledge pre program and significant improved of them were High immediately post and after three month. This means that all head nurses in this study increased their knowledge that reflect on increase quality of nursing care, increase patient safety, decrease medical errors and improve relationship and cooperation among staff members to improve nursing performance.
Present study finding is consistent with the finding of Morsy, (2014) who conduct a study on the effectiveness of implementing clinical supervision models on head nurses’ performance and nurses’ job satisfaction support present study results and revealed that , there were high statistical significant improvements of both head nurses and their assistants’ knowledge and responsibility (perception) about clinical supervision after implementation of the program.
This was agreed with (Cruz et al., 2012) whom conduct a study on Clinical supervision in nursing, support present study results and revealed that participants that emphasize aspects like: In attendance on somebody; life”long learning; professional growth and development; solve problems/situations; process; quality nursing care and safety. (Ping, 2008) refer that clinical supervision to be effective ‘needs to be a planned teaching and supervision session to develop independent practitioner with problem-solving skills, self-directed learning ability, autonomy and life-long capability’
In the same line, Health Workforce Australia (2011) who conduct a study on Clinical Supervision Support Program, support present study results and found that There was strong support for the development of clinical supervision education and training program where leaded to increase knowledge and skills of clinical supervision for stakeholders and they agreeing that the principles should not be overly prescriptive and allow for flexibility for local arrangements to be negotiated.
This also was consistent with Hancox et, al (2004) who reported that, the participants in the educational program conducted for clinical supervision were had positive attitude toward attending the educational program for clinical supervision and they also, reported gained new knowledge that enabled them to be more reflective and confident in their practice as well as provided them with opportunity for sharing new ideas, knowledge and skills and building relationship with their supervisees.
Adequate education and training is necessary to ensure that clinical supervision is conducted in appropriate supportive manner and that clinical supervisors had the essential skills to provide clinical supervision to their supervisees (Cutcliffe and Proctor, 1998).
Tomlinson, (2015) stated that head nurses should be focus on patients’ perception of the quality of nursing care and hospital services. It is increasingly seen as an important measure in examining quality of health care. Perceptions of the quality of care are influenced by the expectations of the person who uses care as well as actual nature of the care being received. A standardized and valid measure that allows comparisons of patients’ perspectives across hospitals and time is important in assessing quality of nursing care.
Consistence with this finding the present study indicated that significant differences in total quality of nursing care as observed in study setting among the three times. Total quality of nursing care was reflected Moderate level of quality of nursing care pre the program which significantly increased immediately post and after three months reflecting that High level of quality of nursing care .
This could be supported by Registration under the Health and Social Care Act (2013) which revealed that Clinical supervision can help to people who use services and their careers receive high quality care at all times from staff that are able to manage the personal and emotional impact of their practice. This also was consistent with Cruz et al., (2014) conduct a study on ‘Clinical Supervision for Safety and Care Quality’ therefore, they carried out a qualitative research to improve patient safety and quality of nursing care through the design of a tool that clarifies each item of the scale and helps nurses in the assessment of the risk of fall.
Moreover, clinical supervision is an approach to sustain quality service and good nursing care practice (Alleyne and Jumaa, 2007). In additional, Health Workforce Australia (2011) stated that Clinical supervisor knowledge and skills reflect a diversity of experience, including opportunities for Patient care provided during clinical placements must be safe, high quality nursing care, appropriate and effective, and be the overriding priority.
Concerning with Raikkonen et al., (2007) who stated that, supervisory support of nurses had an essential impact on quality improvement. Head nurses can affect quality in different ways for instance; through the effect they have on staff performance, stress reduction, job satisfaction, and staff well-being.
This also was consistent with Hyrkas and Paunonen (2001) who examined the effect of clinical supervision on the quality of care. They concluded that, clinical supervision has positive effects on quality of care and it can be considered as a quality improving tool/intervention in nursing practice. Effects of clinical supervision on the quality of care are a key aspect in the improvement of quality and they were defined as a target area ( Hyrkas & Lethi , 2003).
While, this result is inconsistent with the findings of Uys et, al., (2005) which revealed that, there was no significant difference in the observed quality of care before and after the training on clinical supervision.
The results of the present study revealed Positive correlation between knowledge of head nurses’ regarding clinical supervision and nurses’ perception of clinical supervision, as well as quality of nursing care pre, immediately post and after three months of the program implementation. In addition, negative correlation between Knowledge of head nurses’ regarding clinical supervision and quality of nursing care as observed pre the program while there was positive correlation immediately post and after three months of the program implementation. This means head nurses learned and develop self-sufficiency in the ongoing acquirement of skills and knowledge from all topics of clinical supervision, its elements, and how to implement the clinical supervision for nurses, which reflected on improving nurses’ perception of clinical supervision and their performance which might be lead to improvement in the quality of the care they provided to their patients.
This result is consistent with Hyrkas et,al., (2006, 2001) who found that, quality of care was positively correlated with clinical supervision and nurses’ perception of clinical supervision provided by their managers.
This result agrees with Jones (2003) and Teasdal et,al (2001) clarified that, good relationship and contact of nurses with their nurse manager/clinical supervisor is a Potential mean for working constructively with other, bring about renewed, flexible harmonious relationship with colleagues and improve their performance that bear positive effect on clinical care management and patients’ welfare.
In this respect, Francke & Graaff, (2012) concluded that, clinical supervision training has a positive effect on head nurses in managing their time and having a sense of being in control of the clinical situations, that allow them to find time to give more concern and support for nurses which help them to develop professionally and positive impact on quality nursing care.
While, the result is inconsistent with Uys et,al., (2005) who found no positive relationship between clinical supervision intervention and the quality of care provided. They stated, although the training on clinical supervision influenced supervision provided by nurse managers, but changes were not sufficient to change the quality of care. Also, Hallberg et, al., (1993) stated that, it seems harder to prove the impact of clinical supervision on quality of care because of the stress caused by psychological demands on care.
7. Conclusion : Highly improvement was found post program toward head nurses’ knowledge in all topics of clinical supervision. Moreover, nurses, perception of Clinical supervision toward effective quality nursing care enhanced, though its functions remain focused on good quality of nursing care and professional wellbeing. The evidence linking clinical supervision to the quality of nursing care reveals that supervision is most effective when its educational and supportive functions are continuously.
8. Recommendations:
Based on the results of the study the following recommendations are suggested:
– Hospital managers should be initiate a supervision program based on the job description for nurse’s supervisors to meet their needs in nursing care and motivate head nurses to use different new educational strategies to conduct the clinical supervision session and ensure regular attendance of staff nurses.
– The clinical supervision program should be periodically conducted for all head nurses.
– Hospital administrators should be utilized staff development department for health teaching for each department.
– Head nurses need to appoint periodically nursing group meeting to verbalized, vitalize and support peer and social interaction.
– Head nurses should be identifying training needs of staff nursing and continuing development needs.
– Great attention of supervisors to plan for conducting nursing working shop to improve quality of nursing care and patient safety.
– Regular evaluation of quality nursing care, rewarding good quality and giving them feedback..
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