Supervision as a focal point in nurse education: An exploratory study of its effects on the needs of student nurses

Adrian Parker, Kerstin Segesten and Lena Svensson

This study reports the results of a 2 year follow up of the effects of experience of supervision on the personal needs of nursing students. Supervision was given during this period on a continual basis as a focal point of nursing education. Students were encouraged to relate critical incidents as starting points for the supervisory process. Students rated the quality of supervision in terms of its perceived effect on their sense of professional identity and on their self-confidence with respect to clinical work. A Swedish version of a standard personality questionnaire, the Edwards Personal Preference Schedule (EPPS), was given at the initiation of supervision and repeated 2 years later on its completion. The results of 48 students are presented. Two hypotheses relating to the global effects of supervision were not confirmed but the hypothesis concerning the effects of supervision to depend on its perceived quality was confirmed. As measured, the effectiveness of supervision was seen in statistically significant correlations between ratings of supervisory quality and changes reflecting an increased need for leadership and a diminished need for subordinance.

INTRODUCTION

The process of acquiring professional competence in nursing can be regarded as involving development of three areas: theoreti- cal knowledge, practical skills and personal

Adrian Parker PhD Licensed Psychologist, Lecturer in Psychology, Department of Psychology, University of Gothenburg, Box 14156,400 20 Gothenburg, Sweden, Kerstin Segesten PhD RN Lecturer in Nursing Science, Gothenburg College of Health and Caring Sciences, Billerudsgatan 1,416 75 Gothenburg, Sweden Lena Svensson Deceased, formerly Research Assistant, Gothenburg College of Health and Caring Sciences (Requests for offprints to API Manuscript accepted 3 March 1993

qualities. The latter, although much neglected, may enable the realisation of the knowledge gained in the first two areas. Personal qualities would seem to include such assets as a reality based form of self-confidence, empathy and caring skills. These qualities may be particularly crucial for the nursing profession in considera- tion of its primary care of individuals and their relatives who are often in states of life and death crises.

The relationship of knowledge to personality is nevertheless an area which has been of little interest in traditional forms of professional edu- cation and has only recently been brought into focus by the seminal work of Patricia Benner (1984, 1991). Benner in her description of how expertise develops, emphasizes that experiential

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learning becomes integrated into personality to create a holistic way of seeing and relating. Such processes are however likely to require some adjustment in the personality and needs of the individual. Unaided, it is also likely that not all individuals are able to benefit from the potential multitude of ‘critical learning incidents’ that nursing education provides. Indeed, loss of ideals and disillusionment have often been reported as occurring during nurse education (Kelly 1991). Moreover personality traits and needs such as low self-confidence, dependency, and lack of assertiveness have been found to be associated with burn-out (Gann 1979, Heckman 1980 cited in Bradham et al 1990).

From this perspective a strong argument can be made for enlarging the role of supervision given to nursing students to occupy a more central place in their education. However, before such a step can be taken, more research evidently is needed to document the efficacy of supervision. The present project attempts to provide an initial basis for the evaluation of the effects of supervision on the needs and person- ality of nursing students. It reports the results of a 2 year pilot study of the effects of a provisional change in nurse education inaugurated at the Gothenburg College of Health and Caring Sciences (Sweden). In the new curriculum, during the trial period from 1989 to 1991, students have received supervision as a continu- ous theme and focal point for experiential learn- ing during the 2 year educational programme.

Some studies have looked at the effects of supervision on qualified nurses, often those wishing to specialise in counselling or psycho- therapy. For instance a Finnish study by Pau- nonen (1991) found that nurses after having taken part in a 1 year supervisory programme in the context of training in counselling, showed on a test of personality needs a greater ‘willingness to act’ on the world around. A study by Bradham and co-workers (1990) looked at the changes that occurred in the needs of nurses who entered degree and non-degree nursing. Assessment was by means of an instrument based on Murray’s Need Theory (similar to the one used in the present study). However, no mention is made of the role of supervision in the educational pro- grammes and such changes that occurred were minor and mainly concerned an increased need for dominance amongst the degree students on completing their programme.

A possible explanation for the lack of research on this topic is that many nursing programmes are still in the process of revision with, as yet, not having systematically integrated supervision as a major theme in the education. Olsson & Gullberg (1987) report that in spite of apparent changes in curriculum and educational objectives, pro- fessional roles are still acquired according to the maintenance model.

METHOD

RESEARCHONTHENEEDSOF NURSES

There is much current debate on the form and role of supervision in nurse education (Armitage & Burnard 1991, Bodley 1991, Marriot 1991, Slevin & Lavery 1991) with an apparent consen- sus that supervision, rather than following the maintenance model, should be in the form of a mentorship aimed at facilitating the student’s personal, theoretical and practical skills. There is nevertheless a dearth of research concerning its actual effectiveness as an agent in bringing about change in these skills.

The project was carried out during a 2 year period using groups of student nurses and supervisors who had participated in supervision throughout this period. Educational priorities did however not permit the preferred use of a matched control design. For this reason the design chosen was essentially a correlational one with the purpose of illuminating the relationship between supervision and change in personal needs. The Edward’s Personal Preference Schedule (EPPS) was used to give a profile of the personal needs of nurse students at the begin- ning of their education and at its termination. The scale was administered during the first few weeks of the first year and re-administered during the last weeks of the second year. The

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ratings of supervision were carried out just before termination of supervision. Although previous research indicates that many needs and traits of personality are resistant to change (Bradham et al 1990), it was reasoned that effective supervision, with its emphasis on the use of critical incidents, might be able to facilitate some degree of re-evaluation or re-integration of certain needs. Supervision was however not intended to be psychotherapy, but rather a forum for gaining insight into one’s own needs and the needs of others which arise in a caring profession.

Students

All 90 students who began their basic 2 year educational programme in nursing received supervision as a continual and central aspect of their education. In Sweden, several specialities exist within nursing education. For the purposes of the present report, data were selected only from the 60 students who were admitted to the programme with General Health Care as a speciality. 48 completed forms were obtained. The loss of 12 cases is explained by the inability of these students to remember their own codes on re-completing the questionnaires 3-4 terms later. Personal codes were used in order to maintain confidentiality by having otherwise anonymous reports, but codes were necessary in order to compare data from the beginning of supervision with that at its termination.

Supervision

Students took part in supervision groups comprising seven to eight members, the groups received supervision during a period of one and half hours and met every other week for this purpose. Supervisory sessions took place as part of the theory periods which were included in the clinical placements. Supervision was intended to be problem oriented rather than task oriented and was defined in the present context as a discussion forum where students worked through difficulties relating to nursing and the nursing role. The aim was to create a therapeutic atmosphere in which personal growth could be

facilitated. Particular emphasis was placed on so-called critical learning incidents (Smith & Russel 1991) in which students report events which have made an emotional impact on them and which potentially offer rich opportunities for experiential learning. A requirement was therefore that every student would write his or her own ‘process notes’: a personal diary of his or her experiences during supervision.

Supervisors

These were recruited from lecturers in nursing science. Each student group had their own supervisor. The supervisors formed in turn groups which received supervision from three external supervisors - so-called ‘super-supervi- sors’. These sessions alternated with those in which supervisors gave supervision to the nurse students, by taking place during the weeks when the latter were not receiving supervision. In addition supervisors received a short course on supervisory skills.

EPPS

This is a questionnaire based on Henry Murray’s need theory aimed at measuring the basic needs in a normal personality such as affiliation, domi- nance, achievement, autonomy, order (NFER 1977). A shortened version of The Edward’s questionnaire is used in Sweden with some of the items given a clearer terminology in view of research findings (Rubenowitz 1963). 14 of the original 15 factors were retained (het- erosexuality was omitted); need for dominance was renamed as need for leadership, deference was given as subordinance, and succorance as need to help others.

Rating scales for supervision

Two ratings scales O-10 with a midpoint 5 were used for students to assess the effectiveness of supervision. Students were asked to rate independently the degree to which supervision achieved its two goals of improving self-con- fidence in working relations and of improving one’s sense of professional identity.

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HYPOTHESES

It was reasoned that supervision per se might have an effect on various needs but also that its effects would probably be contingent on its experiential value for students as reflected in their assessment ratings of its quality. Hypotheses were formulated and written in advance of the analysis. They would be evalu- ated as supported if statistical analysis reached or surpassed the conventional (P 5 0.05) level of significance.

1. It was hypothesised that of the 14 needs measured by the EPPS, those most likely to change (in the positive direction by gaining increased loading) as a result of supervision would be autonomy, introspection, leader- ship and the need for change itself.

2. It was hypothesised that the effectiveness of supervision as measured by the self- report rating scale would correlate posi- tively and significantly with changes in the above needs.

3. It was further hypothesised that an overall non-specific change in needs (as reflected by the sum of scores on the EPPS) would occur and that this would be correlated positively with the ratings of the effectiveness of supervision.

RESULTS

Comparison of scores on the EPPS showed there was no overall significant change in the structure of needs from the point of entry into nursing education to its exit. Examination of specific needs in accordance with the first hypothesis showed there to be neither a significant change in any of these factors nor indeed in any of the other 10 needs measured by the EPPS. However, on comparing the total scores measuring changes in needs (before versus after EPPS scores) these were found to correlate positively and significantly with ratings of the effect of supervision on professional identity (rho 0.34, P < 0.02). A marginally significant effect (rho 0.29, P < 0.05) was also observed for ratings of

supervisions effect on self-confidence and over- all change in personal needs. Some support could then be considered to have been found for hypothesis two in the form of these low, albeit significant, correlations between the relevant variables.

Overall change in personal needs was simply calculated by summing the differences between test and retests scores on the EPPS. An examin- ation of changes in specific needs indicated a positive and significant change to occur as pre- dicted (in hypothesis three) for one of the specific needs. This was the need for taking leadership and gave a significant correlation with the perceived effectiveness of supervision on professional identity (rho 0.29, P < 0.05). The correlation between the need for taking leadership and increased self-confidence just failed to reach conventional significance (rho 0.28, P < 0.06). However, it is the direction of such changes that are important. Further ana- lyses, which took this into account, indicated that the statistical significance is entirely accounted for by the majority of students (26 out of 40) who showed this change in the direction of an increased need for leadership (rho 0.42, P < 0.03).

A post-hoc analysis revealed changes in the need for subordinance to also be significantly correlated with the judged effectiveness of supervision - specifically in improving self-con- fidence. Subordinate or deference is described as the need ‘to get suggestions from others, do what is expected, to praise others, to follow instructions.’ How do we reconcile this with the findings above? As might be expected the signifi- cance is accounted for by the majority of students showing change in this factor in terms of a decreased need for subordinance (23 showed a decrement, 14 an increment and the remainder no change). A separate analysis for this group studying only these individuals (N = 37) who showed a change in the need for subordinance gave a highly significant corre- lation (rho 0.93 P < 0.0001) between super- vision’s effect on self-confidence and a change in this need as recorded by the EPPS. While par- tially a post-hoc analysis, the high level of signifi- cance indicates that the finding merits attention.

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It may be, for instance, that only certain students are receptive to supervision but on the other hand these individuals may benefit highly from it.

The students’ evaluation of supervision was clearly positive giving a mean rating of 7.2 with a standard deviation of 2.6 for its effect on pro- fessional identity. This was an impression which was also confirmed by the process notes which often reiterated the value of having supervision as a focal point for the educational programme. Its effect on self-confidence in working relation- ships was as might be expected somewhat lower (mean 6, 4, standard deviation 1.8).

CONCLUSION

A major difficulty in evaluating the effects of supervision is that the very experience of college education is hard to isolate from that of super- vision. Indeed, a general finding in this area is that further education leads in itself to a liberalis- ing of students’ attitudes (Feldman & Newcomb 1969, Anderson & Bryjak 1989). In the present context, supervision was seen as a means for maximising the educational and clinical experi- ences of student nurses by the working through of critical incidents. We attempted to identify its effect by using rating sales together with person- ality testing before and after supervision.

There is, of course, inevitably some difficulty in drawing firm conclusions from such self- report data. In the first instance, the nature of correlational findings and the source of the data being entirely the experiences of student nurses, raises the question of whether the results are tautologous due to confounding of the measures. The question must be posed, is it merely that students who adjust to the demands of the supervisory situation reflect this adjust- ment as a change in certain needs? However, even granting this possibility, it is quite a step from a group supervisory situation to the filling in of a questionnaire, and the evidence of changes in specific areas would seem to guaran- tee that whatever the nature of the supervisory relationship, it does have an effect on how the

student experiences needs. A further caveat is the risk of over-analysis of this kind of data where the interaction between many variables are studied. For this reason, we were careful to limit the number of hypotheses and distinguish between predictions and post-hoc analyses.

What is interesting is that the results make psychological sense. It is surely no coincidence that the needs most suceptible to change are just those which are currently most involved in the changing state of development in the role of the nurse. The majority of students experienced supervision as effective and helpful, and also experienced change in the form of an increased need of leadership and diminished need for subordinance. Moreover that a diminished need for subordinance is associated with supervision’s positive effect on self-confidence would again seem natural and undoubtedly an issue of con- cern to student nurses. Given the previously mentioned findings suggesting that personal needs are resistent to change over time, the above findings can be considered as validating the effectiveness of good (as experienced) super- vision.

It is true that supervision as a generally effective means of promoting personal and pro- fessional growth was not reported here as being effective on the measures used. Nevertheless, it should be stressed that the measures used here were by any account crude ones and conclusions about the effectiveness of supervision are limited to the area of personal needs (as defined by Murray and Edwards).

On the positive side, some fairly consistent evidence was found here for the effectiveness of supervision when its experienced quality is taken into account. In this respect such findings are parallel to those reported in psychotherapy research (Truax 8c Carkhuff 1967) and can be interpretated as giving emphasis to the quality of supervisory experience as determining out- come. The form of supervision used here was ‘process orientated’ but it is also possible to include a more formal content such as role-play and empathy training (Burnard 1989) and per- haps a more formal use of critical incidents. This would enable us to also go beyond the subjective and show that supervision also has an effect on

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the utilisation of knowledge in the form of Burnard P 1 WI Counselling skills for health

professional competence. professionals. Chapman and Hall, London

Feldman F A, Newcomb T M 1969 The imoact of college on students. Josssey-Bass, San Francisco

Kelly B The professional values of English nursing undergraduates. Journal of Advanced Nursing 16:

References 867-872

Marriot A 1991 The support, supervision and instruction of nurse learners in clinical areas: a

Anderson J, Bryjak G 1989 Out of the tower and into literature review. Nurse Education Today 11: 261- the street: University students and social iustice issues. 269 Educational Quarteily 13: 47-56 ”

Armitage P, Burnard P 1991 Mentors or perceptors? Narrowing the theory-practice gap. Nurse Education Today 11: 225-229

Benner P 1984 From novice to expert, excellence and power in clinical nursing practice. Menlo Park, CA, Addison-Wesley

Benner P 1991a The role of experience, narrative and community in skilled ethical comportment. Paper presented at Human Science Conference, Cothenburg

Benner P 199 1 b From beginner to expert: gaining a differentiated clinical world in critical care nursing. Paper presented at Human Science Conference, Gothenburg

Bodley D 199 1 Adapting supervision strategies to meet the challenges of future mental health nursing practice. Nurse Education Today 11: 378-386

Bradham C, Dalme F, Thompson P Personality traits valued by practicing nurses and measured in nursing students. Journal of Nursing Education 29: 225-232

NFER 1977 Catalogue of psychological tests. National Foundation for Educational Research. UK

Olsson H, Gullberg M 1987 Nursing education and professional role acquisition. A longitudinal study of expectations and attitudes towards nurse role acquisition. Nurse Education Today 7: 270-277

Paunonen M 199 1 Changes initiated by a nursing supervision programme: an analysis based on log- linear models. Journal of Advanced Nursing 16: 982- 986

Rubenowitz S 1963 Emotional flexibility-rigidity as a comprehensive dimension of mind. Almquist & Wiksell, Stockholm

Selvin 0, Lavery M 199 1 Self directed learning and student supervision. Nurse Education Today 11: 368- 377

Smith A, Russel J 1991 Using critical learning incidents in nurse education. Nurse Education Today 11: 284- 291

Truax & Carkhuff 1967 Towards effective counselling and psychotherapy. Aldine Press, Chicago.