Supervision

2.1 Nature of supervision

Development of its nature is a process of becoming. We build on what is already present.
The concept of readiness, which has lost some ground in the face of the modern
determination that all skills can be taught once they are named, is important for true
development. You cannot put the roof on a house until the walls are built. If you attempt
to do so the emergent structure will be at best shaky. In facilitating the development of
interpersonal ability the readiness of the supervisee is of primary importance. The major
difficulty is that neither the supervisee nor the supervisor knows in any conscious way
just what the supervisee is ready to develop and what the steps are likely to be. Help is at
hand. The supervisee brings something to supervision that they want to examine. Within
this lies the material through which progress and development can occur. The
unconscious, not dominated by the ego has truth in its sight. This hints at the importance
of the supervisors not leading the supervisee towards a way forward but rather
assisting a reflective exploration of the supervisees experience. Out of this the way
forward will emerge.
Clinical supervision
An activity that brings skilled supervisors and practitioners together in order to reflect
upon their practice. "Supervision aims to identify solutions to problems, improve practice
and increase understanding of professional issues" UKCC (1996). There are various
models or approaches to clinical supervision; one-to-one supervision, group supervision,
peer group supervision. The choice of approach will depend upon a number of factors,
including personal choice, access to supervision, length of experience, qualifications,
availability of supervisory groups, etc.
Supervision is used in counselling, psychotherapy, and other mental health disciplines as
well as many other professions engaged in working with people. Supervision may be
applied as well to practitioners in somatic disciplines for their preparatory work for
patients as well as collateral with patients. Supervision is a replacement instead of formal
retrospective inspection, delivering evidence about the skills of the supervised
practitioners.
It consists of the practitioner meeting regularly with another professional, not necessarily
more senior, but normally with training in the skills of supervision, to discuss casework
and other professional issues in a structured way. This is often known as clinical or
counselling supervision or consultation. The purpose is to assist the practitioner to learn
from his or her experience and progress in expertise, as well as to ensure good service to
the client or patient. Learning shall be applied to planning work as well as to diagnostic
work and therapeutic work.

Purpose of supervision
To persist in the delivery of high quality of health care services.
To assist and to help in the development of staff to their highest potential.
To interpret the policies, objectives, needs etc.
To plan services cooperatively and to develop coordination to around overlapping.
To develop standards of service and method of evaluation of personnel and services.
To assist in problem solving of the matters concerning personnel, administrative and
operation of services.
To evaluate the services given.

2.2 Functions of supervision

Administrative function
Teaching
Helping
Linking
Evaluation
Orientation of newly posted staff
Assessment of the workload of individuals and groups
Arranging for the flow of materials
Coordination of efforts
Promotion of effectiveness of workers and social contact
Helping the individuals to cope
Facilitating the flow of communication
Raising the level of motivation
Establishment of control
Record keeping

Principles of supervision
Supervision strives to make the ward a good learning situation.
Supervision of graduate staff nurses differs from that of students in general respect.
Good supervision is well planned objectives methods of supervision and criteria for
judging.
It helps her attain her objectives. It stimulates her interest and effort.
It helps the nurse to make a pattern for analysis and to analyze continuously her
success in reaching her objectives.
2.3 Techniques for supervision
Observation
Supervisory rounds
Individual and group conferences

Checklist
Rating scales
Written policies, printed manuals, bulletin records etc.
Report written or verbal
Records including anecdotal records
Follow up visits and evaluation
Staff meeting
In service education

2.4 Nurse Supervision limits

Assess health needs

Provide care
Advise and support people to manage their health
Manage, teach, evaluate nursing practice
Gathering evidence that health out comes will be assigned

2. 5 Sharing Supervision
Ethical decision making - to explore the decision-making style and ethical approach
of nurse supervisors by focusing on their priorities and interventions in the
supervision process.
Task delegation - defined as transfer of responsibility for the performance of patient
care while retaining accountability for the outcome.
Purchasing - refers to a business or organization attempting to acquiring goods or
services to accomplish the goals of its enterprise.
2.6 Supervisors role models
DEVELOPMENTAL MODELS
Underlying developmental models of supervision is the notion that we each are
continuously growing, in fits and starts, in growth spurts and patterns. In combining our
experience and hereditary predispositions we develop strengths and growth areas.Studies
revealed the behavior of supervisors changed as supervisees gained experience, and the
supervisory relationship also changed. There appeared to be a scientific basis for
developmental trends and patterns in supervision.Stoltenberg and Delworth (1987)
described a developmental model with three levels of supervisees: beginning,
intermediate, and advanced. Within each level the authors noted a trend to begin in a
rigid, shallow, imitative way and move toward more competence, self-assurance, and
self-reliance for each level. Particular attention is paid to (1) self-and-other awareness, (2)
motivation, and (3) autonomy. For example, typical development in beginning

supervisees would find them relatively dependent on the supervisor to diagnose clients
and establish plans for therapy. Intermediate supervisees would depend on supervisors for
an understanding of difficult clients, but would chafe at suggestions about others.
Resistance, avoidance, or conflict is typical of this stage, because supervisee self-concept
is easily threatened. Advanced supervisees function independently, seek consultation
when appropriate, and feel responsible for their correct and incorrect decisions.
Once you understand that these levels each include three processes (awareness,
motivation, autonomy), Stoltenberg and Delworth (1987) then highlight content of eight
growth areas for each supervisee. The eight areas are: intervention, skills competence,
assessment techniques, interpersonal assessment, client conceptualization, individual
differences, theoretical orientation, treatment goals and plans, and professional ethics.
Helping supervisees identify their own strengths and growth areas enables them to be
responsible for their life-long development as both therapists and supervisors.
INTEGRATED MODELS
Because many therapists view themselves as "eclectic," integrating several theories into a
consistent practice, some models of supervision were designed to be employed with
multiple therapeutic orientations. Bernard's (Bernard & Goodyear,1992) Discrimination
Model purports to be "a-theoretical." It combines an attention to three supervisory roles
with three areas of focus. Supervisors might take on a role of "teacher" when they
directly lecture, instruct, and inform the supervisee. Supervisors may act as counselors
when they assist supervisees in noticing their own "blind spots" or the manner in which
they are unconsciously "hooked" by a client's issue. When supervisors relate as
colleagues during co-therapy they might act in a "consultant" role. Each of the three roles
is task-specific for the purpose of identifying issues in supervision. Supervisors must be
sensitive toward an unethical reliance on dual relationships. For example, the purpose of
adopting a "counselor" role in supervision is the identification of unresolved issues
clouding a therapeutic relationship. If these issues require ongoing counseling,
supervisees should pursue that work with their own therapists.
The Discrimination Model also highlights three areas of focus for skill building: process,
conceptualization, and personalization. "Process" issues examine how communication is
conveyed. For example, is the supervisee reflecting the client's emotion, did the
supervisee reframe the situation, could the use of paradox help the client be less resistant?
Conceptualization issues include how well supervisees can explain their application of a
specific theory to a particular case--how well they see the big picture--as well as what
reasons supervisees may have for what to do next. Personalization issues pertain to
counselors' use of their persons in therapy, in order that all involved are nondefensively
present in the relationship. For example, my usual body language might be intimidating
to some clients, or you might not notice your client is physically attracted to you.
The Discrimination Model is primarily a training model. It assumes each of us now have
habits of attending to some roles and issues mentioned above. When you identify your
customary practice, you can then remind yourself of the other two categories. In this way,

you choose interventions geared to the needs of the supervisee instead of your own
preferences and learning style.
ORIENTATION-SPECIFIC MODELS
Counselors who adopt a particular brand of therapy (e.g. Adlerian, solution-focused,
behavioral, etc.) oftentimes believe that the best "supervision" is analysis of practice for
true adherence to the therapy. The situation is analogous to the sports enthusiast who
believes the best future coach would be a person who excelled in the same sport at the
high school, college, and professional levels. Ekstein and Wallerstein (cited in Leddick &
Bernard, 1980) described psychoanalytic supervision as occurring in stages. During the
opening stages the supervisee and supervisor eye each other for signs of expertise and
weakness. This leads to each person attributing a degree of influence or authority to the
other. The mid-stage is characterized by conflict, defensiveness, avoiding, or attacking.
Resolution leads to a "working" stage for supervision. The last stage is characterized by a
more silent supervisor encouraging supervisees in their tendency toward independence.
Behavioral supervision views client problems as learning problems; therefore it requires
two skills: 1) identification of the problem, and (2) selection of the appropriate learning
technique (Leddick & Bernard, 1980). Supervisees can participate as co-therapists to
maximize modeling and increase the proximity of reinforcement. Supervisees also can
engage in behavioral rehearsal prior to working with clients.
Carl Rogers (cited in Leddick & Bernard, 1980) outlined a program of graduated
experiences for supervision in client-centered therapy. Group therapy and a practicum
were the core of these experiences. The most important aspect of supervision was
modeling of the necessary and sufficient conditions of empathy, genuineness, and
unconditional positive regard.
Systemic therapists (McDaniel, Weber, & McKeever, 1983) argue that supervision should
be therapy-based and theoretically consistent. Therefore, if counseling is structural,
supervision should provide clear boundaries between supervisor and therapist. Strategic
supervisors could first manipulate supervisees to change their behavior, then once
behavior is altered, initiate discussions aimed at supervisee insight.
Bernard and Goodyear (1992) summarized advantages and disadvantages of
psychotherapy-based supervision models. When the supervisee and supervisor share the
same orientation, modeling is maximized as the supervisor teaches--and theory is more
integrated into training. When orientations clash, conflict or parallel process issues may
predominate.

2.7 Trends Affecting Supervision

1. Budget
Despite the claims of your Economics 101 professor, much of healthcare expenditure
does not come from inelastic, necessary goods. Instead, the "just in case" procedures are
put off as patients adopt an "only-if-I-have-to" mentality.

This all begs the question: What do I do when my hospital

system/facility/department/unit has had a budget cut? Here are a few tips to consider:
Look for innovative ways to reduce your budget. Ask yourself these questions to
brainstorm ideas:
Do you have the opportunity to consolidate nursing units?
Can charge nurses care for a limited number of patients?
Can you reduce the time that new employees spend in orientation?
Is there any way you can improve employee retention
Acknowledge to your leaders that you are aware of the problem. Whether you
answer to the Board or to a charge nurse, it is important that they know you are both
aware of the problem and working to do your part. A good start is providing your
higher-ups with budget status reports and possible resolutions.
When you have a budgetary need (whether it's a new MRI scanner or extra
overtime), make sure it is in context. For example, say, "Based on current
volumes, we will easily pay for this machine in X months," or in the case of
overtime, "It may be cheaper to temporarily use some overtime shifts rather than hire
another nurse."

2. Quality & Safety

When facilities are operating as leanly as possible and budget cuts abound, the first and
foremost concerns remain (and should remain!) quality of care and safety of patients.
How can you ensure that your quality and safety standards are up to par?

Push your specialty nurses to get certified and involved with their local specialty
organizations.
Ensure that you have a monitoring process to evaluate standards of care; Specialty
nursing organizations are an excellent resource.
Monitor key metrics for quality and safety and address any deficiencies.

3. Patient Satisfaction
More often than not, operational issues are a major contributor to patients' overall
satisfaction, and we've compiled a list of key indicators you should consider at your own
facility:

With a large percentage of patients admitting from the emergency department, ED

satisfaction is a key part to the equation. Number one on this list is improving
patient flow and reducing length of stay (read more: Your ED: 5 Steps to Shorter
Stays & Happier Patients).
The other major admitting point is surgical services. Ease of the admitting
process, communication, education, and discharge are key factors for increasing
patient satisfaction in the perioperative arena.
Last, but definitely not least, are inpatient units. Some of the same rules apply

including communication and education, however timeliness of treatments and

medication are also considered significant patient satisfaction indicators.
4. Staffing
Getting the right person into the right position can be tough, especially when discussing
management vacancies. A few tips to ensure you have the appropriate staffing model
include:

Evaluation of alternative staffing models based on existing resources in your

community. Rather than relying heavily on traveling nurses, how can you more
effectively use existing staff and recruit potential new staff from the community?
Management vacancies, whether over a few weeks or several months, contribute
to significant staffing and retention issues (read more: Three Ways to Fill a
Management Vacancy).
A satisfied staff will result in decreased turnover and increased patient
satisfaction. Consistency and equity with staff schedules and staff assignments,
adequate training of charge nurses, and meeting educational needs all lead to more
satisfied staff.

5. Healthcare Reform
With healthcare reform in full swing, you need to make sure you are prepared:

The impact on hospitals may actually be positive with a larger insured patient
population. Make sure you are appropriately prepared to accept a potential
increase in patient volumes (with staffing, facility capacity, etc.).

Make sure this more expanded patient population knows about your key services.
Marketing targeted services is extremely important and should be well under way
at this point. To better ensure success make sure you have a strong line of
communications between operations and marketing/strategy.