Effect of an Educational Program about Clinical Supervision for First Line Nurse Managers on Quality of Their Clinical Supervision An Educational Program about Quality of Clinical Supervision for First Line Nurse Managers

Introduction

Clinical supervision provides nurses the opportunity to improve quality of patient care and maintaining standards of care provided. In addition, clinical supervision (CS) provides an avenue for nurses to demonstrate active support for each other as professional colleagues, and providing reassurance and validation (1).

Clinical supervision has become a standard practice for health professionals, and considered to be an important component of the comprehensive clinical governance.  Also, CS has been promoted as a key of clinical governance component to ensure the provision of and accountability for the quality of care provided to patients, and to minimizing the risk of adverse outcome. Therefore, improving the quality of care in practice is a challenge for both manager and staff (2).

Moreover, the vital position that held by first-line nurse managers is viewed as the most essential link in the nursing department. Also, many nurses and nurse managers feel that the most future task for them is clinical supervision. So, most of head nurse's functions are concerned with supervision, development of the moral, interest, and satisfaction of the staff nurses in their unit (3).

Furthermore, the position of head nurses is vital at each unit and is one of the most difficult, demanding, and challenging jobs in any organization; where they should assess and evaluate the work performance of nurses, review completed medical forms to assess record keeping abilities, and inspect work areas for organization (4).

Clinical supervisor had to be able to assist and support supervisees in the best possible way, and should demonstrate commitment and empathy. Empathetic supervisors are more successful because they understand what makes supervisees tick and can customize their approaches in order to reach others. In addition, they know how to give supportive, positive feedback, and encouragement (5).

In addition, clinical supervisor should be active, open, and constructively help supervisees to effectively explore and develop clinical practice and allow them to discuss clinical and critical issues openly as the culture of clinical discussion seemed to develop in a more open manner and direction of clinical supervisor. Within these boundaries, explicit parameters should be made with regard to issues which could be addressed and which should not. Also, the work discussion that takes place in CS time offers a sustaining environment for nurses to develop their competencies (6).

Significance of the Study

During the clinical training of the nursing students at Minia University Hospitals, it was observed that first-line nurse managers have little knowledge and experience about personnel management especially staff supervision at different situations in clinical care areas. First-line nurse managers might be aware of the concept of staff supervision but they are lacking the knowledge and sound principles of effective supervision. Effective CS may increase nurses’ perceptions of organizational support and improve their commitment to the organization's vision and goals. CS is helping nurses to avoid medical errors and job-related stress, enhance well-being and improves clinical performance which in turn, leads to improved quality of patient care, clinical decision making abilities of nurses and patient safety. Therefore, carrying out an educational program about CS for first line nurse managers may help them to apply effective leadership behaviors in the field.

Aim of the study:                                                                                                                

The aim of this study was to investigate the effect of an educational program about clinical supervision for first line nurse managers on quality of their clinical supervision.                                                                                                                   

Research Hypothesis:

• H1: The first line nurse managers' knowledge score about clinical supervision will increase after the implementation of an educational program than before implementation.
• H2: The first line nurse managers' quality level and effectiveness of the clinical supervision will be higher after the implementation of an educational program than before implementation.
• H3: Staff nurses' perception of their first line nurse managers level of clinical supervision skills will be higher after the implementation of an educational program than before implementation.

Subjects and method

Research design:

Quasi-experimental design was utilized in this study.

Setting:

The study was carried out at Minia University Hospitals (Minia University Hospital; and Gynecology, Obstetric and Pediatric University Hospitals) . 

Subjects

A convience sample of all available first-line nurse managers' were included in the study (total no= 50 nurse) and staff nurses (تلغى was included in the study) (total no 300 nurse) .        

Tools of data collection:

Three tools were used in this study: Clinical supervision knowledge questionnaire, Manchester Clinical Supervision Scale (MCSS), and Clinical Supervisor self-assessment questionnaire.

Tool I: Clinical supervision knowledge questionnaire, this tool was included two parts as follows:

1^st part was including: Socio-demographic characteristics data sheet for first-line nurse mangers. 

2^nd part: Clinical supervision knowledge questionaire was developed by the researcher based on related literature (7.8.9.10.11) to assess first-line nurse managers' level of knowledge regarding clinical supervision. The scoring system of this tool was divided as follows: Low clinical supervision knowledge (<60%), moderate (60% - >75%), high clinical supervision knowledge (<75% or more).

Tool II: Clinical Supervisor self-assessment questionnaire

This tool was developed by Bond and Holland (2010)12, this tool was categorized by the researcher into7 subscales to measure the quality of the clinical supervision. The tool consisted of 45 items categorized into 7 subscales namely; trust/rapport (four items), supervisor advise/support (six items), improved care/skills (nine items), importance/ value of clinical supervision (ten items), finding time (five items), reflection (sixth items) and personal issues (five items).The questionnaire consisted of 45 items.

 Responses was rated on 5 points likert scale ranging from (5) strongly agree to (1) strongly disagree. The scoring system of this tool was classified as follows: Low level of effectiveness of the clinical supervision (<50%), moderate (50% - > 75%) and high level of effectiveness of the clinical supervision< 75 %.

Tool III: Manchester Clinical Supervision Scale (MCSS), this tool was included two parts as follows:

1st part was including: Socio-demographic characteristics data sheet was developed by the researcher for staff nurses. 

2nd part: Manchester Clinical Supervision Scale (MCSS) was developed by Winstanley (2000) 13, and was adapted by the researcher to measure supervisees' perceptions about the quality and effectiveness of the clinical supervision that provided by first-line nurse managers. The scale consisted of 36 items categorized in 7 subscales namely; trust/rapport (seven items), supervisor advise/support (six items), improved care/skills (seven items), importance/ value of clinical supervision (six items), finding time (four items), reflection (three items) and personal issues (three items).

Responses was rated on 5 point likert scale ranging from (5) strongly agree to (1) strongly disagree. The scoring system of this tool will be classified as follows: Low level of effectiveness of the clinical supervision (<50%), moderate (50% >75%) and high level of effectiveness of the clinical supervision< 75 %.

Validity and reliability

Content validity of the three tools were revised and validated by three experts in the field of study which classified as follows: two Assistant professors of Nursing Administration Department – Faculty of Nursing – Minia University and Assistant professor of Nursing Administration Department – Faculty of Nursing – Assuit University. Accordingly some items were modified.  The reliability for the study tools were done using alpha coefficient to measure the internal consistency reliability of the three tools; it was (0.77) for Clinical supervision knowledge questionnaire, (0.92) for (MCSS), and (0.89) for Clinical Supervisor self-assessment questionnaire.

Pilot Study

A pilot study for the three tools was conducted on 5 head nurses and 30 staff nurses (10%) that were included in the study subjects, selected randomly from the different hospitals departments in order to check applicability of the tools; identify obstacles and problems that may be encountered during data collection and the estimate time needed to fill the questionnaires. In the light of the findings of the pilot study, no changes occurred in the tools and the tools were put in their final form.

Procedure

The study was conducted in three phases: Assessment and planning phase, implementation phase, and evaluation phase.

Assessment and planning phase

• An official permission was obtained from the Dean of Faculty of Nursing- Minia University.
• A review of the related literature which covering various aspects of the problem was done. The review of literature developed in sixth months from beginning of August 2016 to the end of January 2017.
• The researcher developed handout about clinical supervision in sixth months from beginning of October 2016 to the end of March 2017.
• The researcher prepared timetable of the program, the learning environment in which the study was conducted, and all needed resources as (conference rooms in the hospital and data show).
• Implementing phase (implement clinical supervision training program):

Pre-test was done before implementing program using tool (I) Knowledge test and (II) Clinical Supervisor self-assessment questionnaire for the first line nurse manager, and tool (III) Manchester Clinical Supervision Scale for the staff nurses

The program was implemented for three sub-groups, each subgroup contained from 15 to 20 head nurses, and the researcher applied the program for each sub-group on separate time. All sessions were occurred within the working time of the participants in the hospital education building and teaching room.

In the first session the researcher explained the aim of the study, program objectives, content and time table.

At the beginning of each session, the objective of the session was explained. Daily feedback was done about the previous session and at the end of each session there a summary was provided.

The training program was implemented in three months from the beginning of June 2017 to the end of September 2017.

Evaluation of Clinical Supervision Training Program:

Evaluation of the training program was carried out after implementation of clinical supervision training program for first-line nurse managers using the following tools; the post-test knowledge and Clinical Supervisor self-assessment questionnaire; as well as post-test done for staff nurses using Manchester Clinical Supervision Scale. The post test was done three times; first immediately after implementation, after three months, and follow-up after 6 months. 

Ethical considerations       

• This study was granted approval by the Ethical Committee of the Faculty of Nursing, Minia University.
• The researcher explained to first line managers who participate in the study, the aim of the study.
• Informed consents were obtained from all the participants before the procedure enrollments after that a detailed explanation of study objectives was provided.
• The study participants were reassured that their participation was voluntary and they had the right to withdraw from the study at any time if they want that.
• The study participants were reassured that their anonymity was maintained although the study and collected information wouldn't be used except for the purpose of this study and written consent were obtained.

Statistical Analysis

Data were analyzed using the statistical package for social science (SPSS) version 20. Numerical data were expressed as mean and SD. Quantitative data were expressed as frequency and percentage. For quantitative data, comparison between two variables was done using t-test, and comparison between more than two variables used ANOVA test. Relations between different numerical variables were tested using Pearson correlation. Probability (p-value) less than 0.05 was considered significant and less than 0.001 was considered highly significant.

Results   

Table (1): Demographic characteristics of the study subjects (First line managers' and staff nurses)

Table (1) shows that48% of first line managers were in the age  group 40 years or more .  The majority of the sample (96%) were females (60%) were married, the majority (84%) of them had baccalaureate degree  of nursing, nearly to half تلغىmore than one third (44%) had more than 20 years of experience.

Regarding personal and job characteristics of staff nurses, table (1) revealed that more than one third (40.3%) of them, were in the age between 29-39 years, while (76%) of them were females, about two thirds (69%) were married, less than (45.3%) of them had technical degree of nursing, and more than one third (38%) had experiences ranged from 1to10 years.

P1= pre and post the program implementation                P2 = pre and after three months of program implementation

P3= pre and after sixth months of program implementation

Figure (1): Total level of CS knowledge of first line managers’ during different times of testing (n=50)

Figure (1) shows that (76%) of first line managers had low level of knowledge, while (10%) of them had high level of knowledge in pre-test. While at the immediate post-test it was (76%) of them had high level of knowledge and (12%) of them had low knowledge. After three months of program implementation there was little change in knowledge level between first line managers, (72%) of them had high level of knowledge and (16%) of them  had low knowledge. While after sixth months of program implementation  the knowledge level had decrease , (64%) had high level of knowledge and (24%) of them had low level of knowledge with statistically significant differences (p=0.001).

Figure (4): Comparison between first line managers' self-assessment and nurses' Perception about clinical supervision at three different times of measures

In figure (4) it was observed that only (10%) of first line managers' self-assessment and (10.7%) of staff nurses' perception of head nurses had high level of CS before program implementation; while after program implementation, more than three quarter (78%) of first line managers' self-assessment and (79%) nurses' perceptions had high level of CS. These scores were gradually decreased after three and sixth months, with statistically significant differences (p=0.001).