Clinical Supervision in Nursing

Instructional

Across nursing and healthcare, the supervision of students is an important component of training and learning. Clinical placements and the experiential learning experience are essential for developing and applying learned theoretical knowledge in the clinical environment. Undergraduate, graduate, postgraduate and new staff are all some of the unique supervision opportunities for nurses to support. Not every nurse will be interested in formal education, but it is likely they will be a preceptor or supervisor. Therefore it is important nurses understand the skills required for effective supervision. Skills such as reflective practice, assessment and feedback are part of this supervision. Being made to feel welcome and recognised as an important part of the team, just basic socialisation aspects to the nursing team.

Supervision

Supervision is defined “as a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, and is acknowledged to be a life-long process” (Martin, Copley, & Tyack, 2014, p. 201).

“Clinical Supervision is regular, protected time for facilitated, in-depth reflection on clinical practice” (Bond and Holland,1998 p. 12)

Models of Supervision

Proctor’s model of supervision is perhaps the most commonly used within health care. “Supervision towards reflective practice” (Proctor, 2010). Proctor’s framework focuses on 3 areas of supervision:

  1. Normative: managerial aspect of practice and learning, such as professional CPD and core mandatory training.
  2. Formative: educative aspect of developing knowledge and skills in professional development and use self reflection for self awareness development. The aim is “to become increasingly reflective upon practice” within the supervision process (Proctor 2001, p.31).
  3. Restorative: supportive aspect for personal development, improving stress management and burnout prevention.

Clinical Supervision Skills Review Tool 

This Clinical Supervision Skills Review Tool is a helpful resource to review your supervision skills. More about this resource in the video below.

Other resources:

Note: This blog post resources and notes were taken from attending an education session ran by Monash University on supervision.

References

Boud, D., & Molloy, E. (2013). Rethinking models of feedback for learning: the challenge of designAssessment & Evaluation in Higher Education38(6), 698-712.

Carrucan-Wood, L. (2015). Preceptorship: Grounding and growing the next generation. Nursing Review.

Department of Health and Human Services. (2015) Clinical Supervision Skills Review Tool.  Victorian Government, Melbourne.

Hattie, J., & Timperley, H. (2007). The power of feedbackReview of educational research77(1), 81-112.

Martin, P., Copley, J., & Tyack, Z. (2014). Twelve tips for effective clinical supervision based on a narrative literature review and expert opinionMedical teacher36(3), 201-207.

Proctor, B. (2010). Training for the supervision alliance: Attitude, Skills and Intention. In Routledge handbook of clinical supervision (pp. 51-62). Routledge.

Sloan, G., & Watson, H. (2002). Clinical supervision models for nursing: structure, research and limitationsNursing Standard (through 2013)17(4), 41.

Winstanley, J. (2000). Manchester clinical supervision scale. Nursing Standard (through 2013)14(19), 31.

‘Do not interrupt’ Bundled Intervention to Reduce Medication Interruptions.

Journal Club Article: Westbrook, J. I., Li, L., Hooper, T. D., Raban, M. Z., Middleton, S., & Lehnbom, E. C. (2017). Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility studyBMJ Qual Saf, bmjqs-2016.

Aim: Evaluate the effectiveness of a ‘Do not interrupt’ bundled intervention to reduce non-medication-related interruptions to nurses during medication administration.

Method:parallel eight cluster randomised controlled study. Nurses were informed that the study was a direct observational study of medication administration and preparation tasks. Nursing staff were blinded to the study aim focused on interruptions and at baseline were blinded to the intervention. Only intervention ward staff were informed of the intervention subsequently.

Use of real time collected data using the Work Observational Method by Activity Timing Software (WOMBAT).

Setting: 4 wards in 1 hospital. Over 8 weeks and 364.7 hours, 227 nurses were observed administering 4781 medications.

Intervention: Wearing a vest when administering medications; strategies for diverting interruptions; clinician and patient education; and reminders.

Outcome Measures: 

  1. Primary outcome was non-medication-related interruptions during individual medication dose administrations.
  2. Secondary outcomes were total interruption and multitasking rates. A survey of nurses’ experiences was administered.

Intervention: The ‘Do not interrupt’ intervention comprised five ‘bundled’ elements:

  1. Wearing of a ‘Do not interrupt’ medication vest by nurses when preparing and administering medications,
  2. Interactive workshops with nurses regarding the purpose of the intervention to reduce non-medication-related interruptions and to identify local barriers and enablers to intervention use (eg, where to store vests),
  3. Brief standardised education sessions with clinical staff (eg, doctors, allied health),
  4. Patient information, which included why nurses were wearing a vest, and a request not to interrupt nurses during medication administration unless their concern was serious and urgent, or related to their medication. Patients were informed of other nurses and staff from whom to seek help if required,
  5. The use of reminders such as posters and stickers to inform health professionals, patients and visitors not to interrupt nurses during medication rounds for safety reasons.

Results: Baseline characteristics for control and interventions wards were similar.  Due to the observational approach of the study, the impact on influencing behaviours must be considered.

  • At baseline, nurses experienced 57 interruptions/100 administrations, 87.9% were unrelated to the medication task being observed.
  • A significant reduction of 15 non-medication-related interruptions/100 administrations compared with control wards.
  • Medication
  • The intervention more effective reducing interruptions from other nurses, no substantial impact from patient interruptions.
  • Intervention ward nurses reported that vests were time consuming, cumbersome and hot.
  • Only 48% of nurses indicated that they would support the intervention becoming hospital policy.
  •  There was reduction in multitasking rates in the intervention wards compared to control wards.

Discussion: The main aspect was the reduction of interruptions (30%) which potentially (as reduction in medication errors was not measured) translates to a reduction in medication administered errors (MAEs) of 1.8%.

This study was conducted in a paper system, so the impact of electronic medication administration records (eMARs) on reducing medication errors needs to be considered.

If visual aids such as vests are not a preference for nurses, also the infection control issue moving around the ward then educating nurses to deal with interruptions is advocated.

Resources

Hayes, C., Jackson, D., Davidson, P. M., & Power, T. (2015). Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administrationJournal of Clinical Nursing24(21-22), 3063-3076.

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errorsArchives of Internal medicine170(8), 683-690.

Westbrook, J. I., & Ampt, A. (2009). Design, application and testing of the Work Observation Method by Activity Timing (WOMBAT) to measure clinicians’ patterns of work and communication. International Journal of Medical Informatics78, S25-S33.

Flowing Data Simulations

Take a look at this great visual data on the simulations of a day in the life of Americans. Put it to fast and it becomes mesmerising to watch the activities over a 24 hour period of a sample of 1000 people.

Yau, N. (2015). A Day in the Life of an American.

Other time use data:

This shows the amazing visual presentations using technology that can replace reams of words or the same old slide presentation format. Remember, it is the message within the storytelling that is essential as part of a presentation to resonate with the listener. 

Incivility

Incivility

In nursing we are used to terms such as, “eating our young” in the transition from student to graduate nurse, some call this plain ‘bullying‘. Take a look at the below presentation on incivility and look at some of themes that we could incorporate into the healthcare workplace to enhance teamwork within nursing and across the multi-disciplinary team.

Why Being Nice To Your Coworker Is Good For Business by Christine Porath at TEDx University of Nevada

Incivility in Healthcare Resources

Altmiller, G. (2012). Student perceptions of incivility in nursing education: Implications for educators. Nursing Education Perspectives33(1), 15-20.

Clark, C. (2008). The dance of incivility in nursing education as described by nursing faculty and studentsAdvances in Nursing Science31(4), E37-E54.

Spence Laschinger, H. K., Leiter, M., Day, A., & Gilin, D. (2009). Workplace empowerment, incivility, and burnout: Impact on staff nurse recruitment and retention outcomes. Journal of Nursing Management, 17(3), 302-311.

Sprunk, E. A. (2013). Student incivility: Nursing faculty lived experience.

Biohacking

What Is Biohacking?

Biohacking (verb, noun) by Dave Asprey (@Bulletproof):

(v): changing your environment from the inside-out so you have full control of your biology; using your body as your personal laboratory, finding the exact hacks that work for you.

(n) The art and science of becoming superhuman.

Superhuman

So in healthcare this approach could provide a way to deliver individualistic care to suit the biology of the person. Or if they are a biohacker they will likely be very informed of their personal health status and preferences and can drive this personalised approach (#expertpatient)

Biohacking You Can Do It Too by Ellen Jorgensen on TED

Topics related to biohacking from Wikipedia (2018):

Keywords: Biotechnology; Genomics; DNA; Biohacking

Biohacking Resources

Asprey, D. (2018). Going Bulletproof for Beginners. Bulletproof.com

BBC. (2018). Biohacking series.

DIYbio

Genspace

The Personal Genome Project

The Applicability of Community of Inquiry Framework (Journal Club)

Journal Club Article: Smadi, O., Parker, S., Gillham, D., & Müller, A. (2019). The applicability of community of inquiry framework to online nursing education: A cross-sectional studyNurse education in practice34, 17-24.

Background

The lack of rigorous evidence based research to guide e-learning in higher education, which is especially relevant with the rapid adoption of e-learning, which is often part of a blended learning approach (Garrison, 2011).

“While discussion forums and video conferencing are very common in online courses, LMS also include a range of more interactive features and advanced functions such as customized learning pathways, collaborative content, peer interaction and assessment workshops, file sharing, real-time messaging, and wiki forums. However, according to Christie and Jurado (2009), these interactive features are not widely used by the course designers. Shea and Bidjerano (2009b) report that designers of online courses and educational providers are often confused about how to integrate new technologies into online learning environments in ways that will enrich student learning.”

The Community of Inquiry Framework

“The Community of Inquiry framework originated in the work of Dewey (1938), Peirce (1955), and Lipman (2003). Garrison et al. (2000) broadened and adapted the Community of Inquiry framework for e-learning education by viewing it through the lens of social, cognitive, and teaching presences.”

Community of Inquiry framework (Garrison et al., 2000):

  1. Social Presence
  2. Cognitive Presence
  3. Teaching Presence

Study Aim

The projects aims were to explore the following questions:

1. What is the awareness and knowledge of Australian nursing educators about the CoI framework?
2. What is the participants’ attitudes on the applicability of the CoI framework to online nurse education courses?

Study Design

An online survey tool which was divided into three sections:

  1. Demographic information,
  2. The applicability of community of inquiry presences,
  3. Awareness and knowledge of  Community of Inquiry.

Participants: Nurse educators from 34 higher education universities providing nurse education to international students.

Limitations: The survey tool was an adaptation of a validated tool. The limited response from using an online survey approach.

Results

From 138 respondents from a possible 1201 (response rate 11.5%):

    • The current used mode of teaching is blended learning (BL) (83%).
    • Nurse educators ranked BL as the best suited teaching mode for nursing education (90%).
    • Ninety percent (90%) of the participants are involved in curriculum design.
    • (90%) of the participants viewed instructional design and framework as significant to build an online course.
    • However, (70%) declared they don’t use explicit theoretical framework to guide the design/evaluation of online education.
    • Participants highly ranked the three core concepts of CoI framework as applicable for online nursing education.
  • (20%) of the participants are familiar with CoI framework, of them (79%) are likely to recommend CoI framework to a colleague.

Summary

“This study has shown the perceived importance of instructional design and theoretical framework to build an online courses for nurse educators using blended learning. Since Community of Inquiry framework has been shown to improve student satisfaction and decrease attrition in non-health disciplines, the implementation of Community of Inquiry framework in nurse education should be investigated more. Community of Inquiry provides a comprehensive framework relevant to face-to-face, blended, and online education with the potential to embed numerous technology-linked interventions within a Community of Inquiry framework.

These results provide the impetus for further investigation of factors influencing the development of online nurse education including the specific consideration of CoI frameworks.”

Keywords: Community of inquiry; Online education; Theoretical framework; Blended learning; E-learning

Reference

Smadi, O., Parker, S., Gillham, D., & Müller, A. (2019). The applicability of community of inquiry framework to online nursing education: A cross-sectional studyNurse education in practice34, 17-24.

Spaced Learning

Spaced Learning is a “learning method in which highly condensed learning content is repeated three times, with two 10-minute breaks during which distractor activities such as physical activities are performed by the students” (Wikipedia, 2018).

Spaced Learning in School 

Themes from the Monkseaton High School experience:

  • What could do we do better and what we are doing
  • Drivers for change are technology and new science
  • Neurological research focused on learning and retention
  • Repetition of content
  • Culture of sharing amongst teachers

Additional Resources

Keywords: Spaced Learning; Repetition; Sharing; Experience; Cognitive learning; Neuroscience.

References

Eich, E. (2018). The Cognitive Science of Learning Enhancement: Optimizing Long-Term Retention. The University of British Columbia, Department of Psychology.

Kelley, P. (2007). Making Minds: What’s Wrong with Education-and What Should We Do about It?. Routledge. [preview]

Smolen, P., Zhang, Y., & Byrne, J. H. (2016). The right time to learn: mechanisms and optimization of spaced learningNature Reviews Neuroscience17(2), 77.

Storm, B. C. (2011). The benefit of forgetting in thinking and rememberingCurrent Directions in Psychological Science20(5), 291-295.

Nursing Education Network Stats 2018

As part of open access and the #FOANed community, here is a summary of this blogs yearly stats (ending Dec 7, 2018). Thank you to everyone who follows and supports this site.  

Views by Countries (Top 12)

In this one year period there were visitors from 144 different countries.  

Views by Post (Top 12) 

Views & Visitors Monthly Data 2018



Warm wishes for a happy new year from Nursing Education Network. Posts will start again from 8th Jan, 2019. 

Education Delivery Resources

This is part III of organising posts from this blog into grouped resources for the nurse educator, and the focus is on the delivery of education (Part I: The Nurse Educator Role and Part II: Adult Learning Theory).

Subject intended learning outcomes (SILOs) are explicit statements of what a learner is expected to achieve, and to what standard or level of achievement (Biggs and Tang, 2011). When creating nurse education and training in the workplace, simulation centre or higher education setting, the importance of designing intended learning outcomes are vital. ILOs are central to the design of teaching and assessment so should be part of the initial planning phases.

Education Delivery

Choosing the delivery method of the learning activity and any related tasks provides a stage for effective teaching and engagement from the participants perspective. The nurse educator needs to consider the best method/s for delivering content. Here are some education delivery focused resources:

The below links are to the resources focusing on the educator role and education theory.

 

IRIS Cricoid Pressure Trial & Deimplementation (Journal Club)

Journal Club Article: Birenbaum, A., Hajage, D., Roche, S., Ntouba, A., Eurin, M., Cuvillon, P., … & Menut, R. (2018). Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial. JAMA Surgery.

Background: 

Cricoid pressure or Sellick’s maneuver (first described by Dr. Sellick in the 1960’s) aims to reduce the risk of regurgitation. The technique involves the application of pressure over the cricoid cartilage with the thumb and 1-2 additional fingers, to to occlude the esophagus and prevent regurgitation of stomach contents into the upper airway.

Study Aim:

Does the cricoid pressure prevent pulmonary aspiration in patients undergoing rapid sequence induction of anesthesia?

Study Design:

A randomized, double-blind, noninferiority trial conducted across 10 academic centers. Patients undergoing anesthesia with rapid sequence intubation (RSI) were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge. 3472 patients were assigned to cricoid pressure (Sellick group) or a sham procedure group. Mean age was 51 years and 51% were men. Inclusion: all adults; Exclusion: pregnancy.

Key Results: 

Primary measure of pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group.

Secondary Measures:

  • No significant difference in pneumonia, length of stay and mortality.
  • The Cricoid (Sellick maneuver) group had significantly longer intubation time (median, 27 vs. 23 seconds).
  • Longer intubation time >30 seconds, Cricoid 47% vs Sham 40%; P <.001.
  • Comparison of the Cormack and Lehane grade (Grades 3 and 4) in Cricoid (10%) vs Sham (5%; P <.001).
  • All suggests an increased difficulty of tracheal intubation in the Cricoid (Sellick) group.

Summary: 

Investigators summary: “the results failed to demonstrate the noninferiority of a sham procedure in preventing pulmonary aspiration compared with the cricoid pressure. Mortality, pneumonia, and length of stay did not differ significantly between groups, and differences in intubation time and laryngoscopic exposure suggest more difficulties in the Sellick group”.

Nursing Clinical Questions:

  • Is cricoid pressure needed if there is no harm prevention and gives inferior views of the airway?
  • This study population was in theatre, can the results be transferred into the pre-hospital, ED or ICU populations (and in pregnancy)?
  • Should nurses use the evidence base to encourage the deimplementation of ‘ritualistic’ practice? See below in Deimplementation Resources.
  • Should nurses just refuse to perform a non-evidence based procedure?

Additional Resources:

Recommended Viewing on Cricoid: Cricolol by John Hinds on Vimeo.

Deimplementation Resources

Rogers, E. M. (1995) Diffusion of innovations. (5th ed.) Simon and Schuster, New York, USA. [summary article]

Nursing Education Network. (2017) Deimplementation of Practice.

Nursing Education Network. (2016) Human Centred Design.