Research Article

Evaluation of process-oriented supervision of studentnurses: A Swedish case studynhs_628 2..7

Ingegerd Lindquist, rnt, msc,1 Ingrid Johansson, rnt, msc1 and Elisabeth Severinsson, rpn, rnt, mnsc, drph2

1The Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Göteborg, Sweden and2Centre for Women’s, Family and Child Health, Faculty of Health Sciences, Vestfold University College, Tønsberg, Norway

Abstract The value of supervision that is provided to student nurses during their education is high.The aim of this studywas to evaluate the organizational changes in an educational program for Swedish student nurses, focusing onthe content and quality of process-oriented supervision. The research question was: Do the organizationalchanges pertaining to the student nurses’ supervision (its reduced frequency and mandatory nature) influenceits content and quality and, if so, in which ways? The data were collected by focus group discussions and wereanalyzed by a qualitative content analysis. Three themes emerged: difficulties with the new organization, thecontent and learning outcomes of supervision, and the nurse supervisors’ intentions. Supervision is recom-mended in order to achieve the goal of nursing education and to ensure that student nurses gain an under-standing of their experiences, thus equipping them with the professional skills and competence that arerequired to meet patients’ needs.

Key words clinical supervision, focus groups, organization, process-oriented supervision, student nurses.

INTRODUCTION

In nursing education, professional skills are regarded asimportant (Holm et al., 1998; Jerlock et al., 2003). This casestudy focuses on the process-oriented supervision (POS) thatis provided to student nurses at a university in Sweden.Therehas been an increase in research on supervision and severaldefinitions of supervision exist. However, despite the fact thatthere are similarities between them, no definition has beenuniversally accepted (Williams et al., 2005; Rice et al., 2007).Several theories and models have been applied and supervi-sion is organized individually and /or in a group (Berggren &Severinsson, 2011). The benefits of group supervision havebeen reported, although there is considerable variation in itsfrequency and duration (Veeramah, 2002; Barriball et al.,2004). A pedagogical and relational approach facilitates pro-fessional development processes (Severinsson & Sand, 2010;Berggren & Severinsson, 2011). The goals of POS are tostrengthen professional skills and to enhance the quality ofcare (Holm et al., 1998; Johansson et al., 2006; Holm Wiebeet al., 2011). It also has been stated that this process leads toan awareness of different concepts and reflection on clinicalpractice (Lyth, 2000). Hence, POS involves the elements ofclinical practical experience and learning of skills that arerequired to achieve the goal of nursing education. The valueof supervision has been investigated by several researchers in

different clinical contexts and has been found to have animpact on professional competence by enhancing the qualityof care that is given (Magnusson et al., 2002; Veeramah, 2002;Edwards et al., 2005; Nordentoft, 2008; Pettifer & Clouder,2008). The ethical dimension of supervision promotes thesupervisee’s moral responsibility, which becomes visible inthe care of individual patients and their relatives, as well as inthe co-operation with colleagues and other healthcare prac-titioners (Lindh et al., 2007; 2008; 2009; 2010). A previousstudy that applied a student nurse perspective found that thestudents increased their patient attentiveness, empathicability, and personal growth by using their communicationability and insight (Holm et al., 1998). Another study thatfocused on the value of caring in POS highlighted the devel-opment of the ability to create a genuine encounter, beingconscious of one’s own value base, and confirming and beingconfirmed in a relationship that is characterized by learningand consolation (Severinsson, 1998; Johansson et al., 2006;Holm Wiebe et al., 2011).

In Sweden, the nursing study program consists of a 3 yearhigher education degree that comprises 180 credits in theEuropean Credit Transfer System (ECTS). It adheres toEuropean Union directives stating that clinical aspectsshould encompass half of the education. During their clinicalpractice, the student nurses work in different clinical areas(surgical, prehospital, psychiatric care, home care, medicalcare, and child care) where clinical supervision is provided byclinical nurses in practical settings.

This research was carried out at a large university on theWest coast of Sweden, where POS has been provided since

Correspondence address: Elisabeth Severinsson, Södra Gåsekilsvägen 4, SE-43994Onsala, Sweden. Email: elisabeth.severinsson@hive.noReceived 29 March 2011; accepted 20 June 2011.

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1989 to assist student nurses at different educational levels.Since 2008, students have received POS at the university forthree semesters (three, four, and six), which is compulsory innursing education. In addition to the theoretical subjects, thestudents receive POS (in groups of eight-to-nine) that is pro-vided by teachers at the university. According to the SwedishHigher Education Ordinance (Ministry of Education andResearch, 1993), student nurses should develop their valuesand stance and demonstrate the following: (i) self-awarenessand empathy; (ii) the ability to apply a holistic approach tointervention assessments, based on the relevant scientific,social, and ethical aspects, while paying particular attentionto human rights; (iii) the ability to adopt a professional stancetowards patients and their relatives; and (iv) the ability toidentify the need for further knowledge and to continuouslyupgrade their skills. The goal of POS is set out in the nursingcurriculum’s study program (The Sahlgrenska Academy,Institute of Health and Care Sciences, University of Gothen-burg, 2010).There are two specific learning outcomes that arerelated to POS. From a patient perspective, the goal is tolearn how to discuss the patient’s and family members’ par-ticipation in care, how to discuss and judge ethical problemsin nursing care, and to reflect on patient involvement and inwhich way the patient’s integrity can be preserved. From astudent nurse perspective, the goal is to reflect on one’sability to meet patients, family members, and interprofes-sional teams, as well as on the strengths and weaknesses ofone’s professional competence. The content of the supervi-sory sessions focuses on the students’ development of theirprofessional identity, their ability to enter into dialogue, andtheir ability to reflect on clinical experiences, including thedevelopment of their ethical stance.

As a result of organizational changes to POS, the numberof supervisory sessions has been reduced from 24 to 16 andthe supervision component has been changed from voluntaryto mandatory. During semesters three and four, the studentnurses encounter a nurse teacher who is a qualified supervi-sor for six sessions (each session lasting 90 min). In addition,they meet as a group for four sessions during semester six.Therefore, it is of interest to evaluate the consequences of theorganizational change pertaining to its frequency and theway in which it might influence the content and quality ofPOS.

AIM

The aim of this study was to evaluate the organizationalchanges in an educational program for student nurses byfocusing on the content and quality of POS. The researchquestion was: Do the organizational changes pertaining tothe student nurses’ supervision (its reduced frequency andmandatory nature) influence its content and quality and, if so,in which ways?

METHOD

A case study (Polit & Beck, 2004) was set up to evaluate theorganizational changes to the POS that is provided to studentnurses at a university on the West coast of Sweden. A focus

group discussion was chosen because it is a carefully plannedactivity that is intended to achieve a deeper understandingof specific issues in a climate of tolerance and friendliness(Morgan, 1997; Bamford & Gibson, 2000).

Sample and data collection

Purposive sampling was used to select the nurse teachers whowere involved in POS at the university (Polit & Beck, 2004).The first group of teachers to have experience of supervisingthe new organization of the nursing program during semes-ters three, four, and six was contacted.A letter that containedinformation about the study, including an invitation to par-ticipate in it, was sent to the nine potential participants whoprovided POS to the 70 students who were divided into ninegroups. Information to those who expressed an interest wasprovided by email and a preliminary date for the focus groupinterview was decided. The sample consisted of four nurseteachers who worked as supervisors. They were registerednurses, qualified university teachers, and trained supervisors(30 ECTS) who were working in the education supervisionprogram, POS (cf. Swedish Society of Nursing, 2009). Theirexperience as a registered nurse ranged from 28 to 42 yearsand they had worked for 4–21 years as a supervisor.The focusgroup interview lasted for 2 h, during which two researchers(I.L. and I.J.) asked probing questions that kept the focus ofthe discussion on the topics of interest. The discussions wereaudio-taped and subsequently transcribed verbatim by thefirst author (I.L.) and the second author (I.J.).

Data analysis

There are three strategies that are involved in an interpreta-tive content analysis (Graneheim & Lundman, 2004). First,after completing the data collection, the strategy behind thepreliminary analysis is to create a structure in order to graspa sense of the whole and to identify the essential featuresof the content. The second strategy is to formulate and com-pare the tentative themes and subthemes. In this strategy,the themes in relation to the learning outcomes and the per-spectives of the patients and those of the student nurseswere organized; that is, their ability to meet patients, familymembers, and interprofessional teams. The third strategy is adiscussion and reflection among the co-authors that is aimedat abstracting and deciding on the themes. In this study, twoquestions guided the second part of the analysis:“What is thisabout?” and “What is the underlying meaning?” The samestrategy was applied in order to analyze in which ways thenew organization of POS and the frequency of supervisioninfluenced the quality of the supervision.

Ethical considerations

This study was approved by the Head of the Institute ofHealth and Care Sciences at the University of Gothenburg,Göteborg, Sweden. The principles of confidentiality, volun-tary participation, and informed consent were applied

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(World Medical Association, 2007). Permission to audio-tapethe interviews was granted and the transcripts were locked ina fire-proof filing cabinet.

RESULTS

Three themes in the evaluation of the organizational changesto POS emerged: difficulties with the new organization, thecontent of supervision and learning outcomes of supervision,and the nurse supervisors’ intentions.

The supervisors’ perceptions of difficulties with the neworganization of POS and their consequences were discussed,focusing on the fact that some students were unmotivated interms of participating in the supervision process.A number ofstudents were less engaged due to feeling forced to partici-pate, as attendance was now mandatory. The supervisors’opinion was that some of these students were only markingtime and did not bring situations from their own experience.Thus, they were not aware that such experiences are impor-tant and failed to take responsibility for participating in theprocess. They only attended in order to obtain their creditpoints as part of their education. The way in which the groupmembers are organized is important. In a heterogeneousgroup, it can be difficult to create a safe and trusting climate.The supervisors stated that, despite the fact that the partici-pants in the group were selected randomly, difference andvariety still existed and was positive, although there is aninherent conflict in this form of organization. A supervisorwho asks for x number of situations from clinical experiencewill put the group members under pressure.The key aspect ofPOS is that the students are not required to produce resultsor documents or to sit examinations – supervision is a forumfor reflection. With regard to whether or not supervisionshould be mandatory, the supervisors were of the opinionthat it should be mandatory, as student nurses who need toreflect on themselves might choose to not attend. If thestudent nurses attend, they will become aware of the impor-tance of supervision and later will request it as a resource inorder to improve the quality of their care when working as aregistered nurse. If the course is mandatory, it signals that it isan important part of the nursing education program. Nursingstudents can choose another university if they do not wish totake part in this mandatory part of the educational program,which is clearly stated in the curriculum. Perhaps, theyalso should reflect on their choice of profession, as a nurse’swork is very closely related to patient care and skills, such ascommunication, are necessary.

The other change in the supervision was the frequency ofthe sessions, which influences the continuity of the workingprocess, in that the supervisor and the supervisees losecontact during longer intervals.The gap in semester five inter-rupted the continuity of the supervision, which led to theconclusion that it would have been better to organize super-vision in semester five in order to avoid starting from thebeginning again. Semester six constitutes the last part of theeducational program and focuses on the students’ work iden-tity. By then, the students knew how to use the group due totheir experiences from earlier sessions. They were able tonarrate their clinical experiences from different situations

that they had encountered as a student and, even if theyconsidered themselves to be more or less spectators, theythought “It could have been me”. They identified themselvesas an educated nurse who soon would have the responsibilityof a registered nurse. Therefore, it is natural to reflect onone’s thoughts, feelings, and actions when meeting others.There is no other forum in the educational program wherethe students can express the thoughts and feelings that ariseduring the development of their professional identity.

Overall, the supervisors stated that the organizationalchanges did not seem to influence the content of the super-vision. They said that they were aware of the content thatshould be included in the group sessions. The learning out-comes were achieved by improved professional competenceand development as a result of the changes to the organiza-tion of the POS. With regard to their ability to meet patients,family members, and interprofessional teams and to reflecton the strengths and weaknesses in their professional com-petence, the students described the clinical settings in whichthey did not feel welcome. The students also reflected ontheir strengths and weaknesses in the nursing role. In thethird semester, they more often felt that “I will never managethis”, while in their final semester, they focused on theirstrengths.They considered that they had developed and wereproud about soon becoming a registered nurse. However,they did not claim to be important and instead describedthemselves as a spectator. The supervisors stated that thePOS provided the students with a theoretical understandingof how they could have acted in ethically difficult situations,which can help them to handle future situations as a regis-tered nurse. The subjects that were reflected on were: (i) theethical aspects related to patients’ and family members’ situ-ations; (ii) the ethical aspects related to the ways in whichother healthcare professionals acted; and (iii) the situationsin which they acted themselves.

The supervisors’ strategies for stimulating the students’learning process were, for example, to encourage them to usea diary to write down their experiences and reflections fromclinical practice. It was suggested that the eight students ineach group could use the same diary and could take turnswriting in it after each supervisory session. One of the super-visors described actively encouraging the students to reflecton situations in which they had played an important role inpatient care. In addition, the learning goals should be articu-lated and should form part of the supervisor’s leadershipstyle. However, the supervisors could not ensure that therewas no change in the quality of the supervision per se, as itwas too early to draw such conclusions.

The supervisors’ intention with regard to their supervisoryleadership style was strongly related to the two learning goalsthat are stated in the curriculum. They argued that the stu-dents who are involved in the supervisory groups shouldreact on the basis of their experiences from clinical practice,should learn how to listen to other narratives, and shouldhave the potential to develop a preparedness to act in orderto ensure quality of care. The students should developcourage and dare to act based on their knowledge of differentclinical situations, should trust their own feelings, and shouldstand up for their ideals, as well as be the patient’s advocate

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and voice. All these aspects are evidence of the learningoutcomes from the patient perspective.

Regarding the supervisors’ intention of developing thestudent nurses’ ability and courage to meet patients, familymembers, and interprofessional teams, they attempted tostrengthen the students by encouraging them to meet andinteract with other student nurses. The potential to articulateand share experiences with other students in a secure culture,such as the supervisory group, strengthens the students andenables them to act. In addition, it increases their under-standing of others’ thoughts and actions.They learn to not bejudgmental and to accept that each individual thinks differ-ently and that a diversity of views is important for theirprofessional competence. Listening to the experiences ofothers increases the students’ ability to learn to be responsiveto patients and co-workers. It prepares them to work as agroup and to collaborate in a team. The supervisory groupalso makes it possible to problematize and to generalize fromone’s own experiences.The students are trained in how to usea reflexive way of acting and to develop their preparedness inthe professional encounter. The intention is that this leads topersonal growth, instead of experiences of injustice and fearor a feeling of being offended.The group enables the studentsto develop their self-awareness and strengths and to becomeaware of their weaknesses, as well as to take responsibility fortheir actions. Finally, supervision provides the students withthe ability to understand the meaning of being a nurse.

DISCUSSION

How can the results be interpreted with the focus on thecontent and quality of student nurses’ learning experiencesas a result of attending POS? The case study reveals thatthe content was not affected by the organizational changes.The supervisors were empowered by a special culture thatthey obtained through their experience and training, whichhad shaped their values, attitudes, and perceptions. They hadgreat knowledge, responsibility, and commitment and theywere guided by clear learning objectives.The results revealedthat both the patient perspective and the student nurse per-spective in relation to meeting with the patient, families, andinterprofessional team were the key to success. An interest-ing point was that POS is the only forum in nursing educationwhere the students are given space to talk about theirthoughts and feelings in relation to the development of theirprofessional identity, which suggests that this program shouldbe mandatory in nursing education. This finding echoes theliterature that is related to the quality of supervisors’ skillsand the importance of their ethical decision-making style(Saarikoski & Leino-Kilpi, 2002; Berggren & Severinsson,2006) and highlights the fact that student nurses need toreflect on moral responsibility in practice (Lindh et al., 2008),as well as on the development of moral strength (Lindh et al.,2009).

Process-oriented supervision is part of the learning out-comes in the training of nurses. Learning is very individualand everyone learns in different ways. The possibility oflearning to know oneself and one’s strengths and weaknessesinfluences the development of one’s professional identity. It

is also important to be able to listen to others and oneself, aswell as to express one’s thoughts, feelings, and actions whenmeeting patients, relatives, and colleagues in an environmentthat is characterized by trust. However, as only one group ofsupervisors at the university has worked with the new orga-nizational model, it is too early to draw conclusions as towhether or not it leads to any differences in quality; there-fore, it is intended to study this issue further by, among otherways, evaluating the groups of students.

Although voluntariness is a fundamental idea behindsupervision, the results of this case study support the pro-posal that it should be mandatory during nursing education.However, free will is necessary to ensure that the students’own situations form the content of the supervision. In thiscase study, the students’ level of motivation was affected bythe mandatory aspect, which placed higher demands on thesupervisors. It is a difficult task for the supervisors to respectthe students’ differences while trying to motivate them. Theresults revealed various strategies for motivating the studentswho were perceived as passive. The literature has concludedthat students’ attitudes to supervision change if they under-stand what it means. A study from Australia revealed that90% of the participants reported an increased level of under-standing after completing the program (Hancox et al., 2004).However, this also depends on the supervisors’ attitudes andleadership style. This finding corresponds with that of Sloan(2005), who revealed that the characteristics of a good super-visor, from the supervisee’s perspective, are an ability to formsupportive relationships and having relevant knowledge andclinical skills, as well as a commitment to providing supervi-sion and good listening skills (Nylund & Lindholm, 1999).According to Rice et al. (2007), it is important for the super-visor to feel valued and to gain an increased sense of self-confidence in order to function as a good supervisor. Thus,the supervisor–supervisee relationship is important in super-vision and might be difficult to maintain if the frequency ofthe sessions is changed. However, receiving supervision every3 weeks, instead of every 2 weeks, did not affect the groupprocess as much as was feared in this case study. The factorthat did disrupt the continuity of the supervision was thebreak in semester five, when the process stopped because ofthe recess. The supervisors agreed that the groups need tomeet more than four times in semester six.The students havelearned how to use POS and, in semester six, they are able tocontribute many thoughts and reflections on their future pro-fessional role. The nursing education guidelines are clearlystated in the curriculum to underline the professional aca-demic identity.

The supervisors’ intentions were consistent with the learn-ing outcomes in relation to the patient perspective and thestudent nurse perspective. The students received opportuni-ties to play a role in the management process and to listen toeach other’s stories, thus developing a readiness to act thatleads to good nursing care, at the same time as the learningoutcomes in relation to the patient perspective becameclearer. The virtue of courage evolved in the process and thesupervisor’s intentions included strengthening the studentsto dare to face themselves. The students also had the oppor-tunity to share their experiences with others in the group.

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Therefore, their meetings with patients, families, and theinterprofessional team became much more important. Thestudent nurses developed a professional pride in their workand could achieve a stronger professional identity.

This case study had two methodological limitations. First,the number of participating nurse supervisors was small andthe data collection only occurred on a single occasion at oneuniversity. Two focus group discussions were planned toachieve a deeper understanding of the influence of organiza-tional changes on the student nurses’ learning potential andthe development of their professional identity. However, thesupervisors were unable to participate on a second occasionbecause they were busy with other work at the university.Focus groups use interview schedules but differ in theirscope, nature, and intention from individual research inter-views (Hudson, 2003). Focus groups offer a collective set ofparticipant values, experiences, and observations that arelater interpreted in context. The authors wanted to capturethe focus group discussions for use in future research, wherethe topics would be deepened by means of individual inter-views. The discussions were lively and the interview textsprovided rich descriptions and new knowledge of the contentand value of the organization of supervision. The secondlimitation was that the group was very homogeneous. Thus,another group (e.g. student nurses) might have yielded otheraspects regarding the issues under study.

CONCLUSION

This case study has provided some insight and information onthe supervisors’ perceptions of organizational changes toPOS in a university in Sweden and their intention to motivatestudent nurses to become active in the process.The increasedrecognition of supervision is welcome, but the potential riskof reduced quality, in terms of its content, must be furtherstudied. In order to achieve the intended learning outcomes,continuous supervision is recommended to ensure thatstudent nurses gain an understanding of their clinical expe-riences by integrating theoretical knowledge, thus renderingthem competent to meet patients’ needs. The supervisorshould use strategies to help the students to reflect on thecontent and to enhance the learning outcomes of the nursingeducation program.

ACKNOWLEDGMENT

The authors thank the participants for the time and effortthat they invested in this study.

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