Section Three — Findings and Discussion for the Supervisors of the Nurse Job Rotation Scheme Study
3.1 Introduction
A three day course on supervision for the supervisors of rotatees on the D/E nurse job rotation scheme was provided. The reasons for the creation of that course are explained in 3.2.2. Funding was also provided to evaluate the benefits or otherwise of the supervisors’ course and allowed the further ‘spin off’ of surveying their views about the wider impact of the scheme.
This allowed for two added contributions to the picture we were trying to build about the scheme as a whole. One was the extent of the contribution made by the job rotation scheme to colleagues, supervisors and managers within the organisation. The other was the value of supervision as a retaining/developing tool for nurses working in hard to staff areas.
It should be noted that this study draws on a wealth of knowledge. The parallel study of the perceptions of a sample of nurses currently working as rotation nurses on the scheme (Lucock & Coyne, August 2006), involved people from only one cohort. Their views, because they are so detailed, are valuable but not generalisable. For the same reason, the views of this sample of supervisors are also not generalisable but the main difference between the two studies is that most of the supervisors had experienced the progress of a number of rotation nurses from each cohort over a period of years. They were well placed to comment.
3.1.1 Listening to key voices
As previously mentioned (1.1), the reasons for addressing many of the topics that were selected was to elicit data that could help in the search for common or individual factors that might influence the level of success of the nurse job rotation scheme in general.
In this type of research, it is important that the voices of the participants are heard as well as the voice of the researcher (Lather 1991) so, here, the comments of supervisors will be used to illustrate and validate the findings. Some voices will be heard more than others. There are two reasons for this. First, some speakers sum up succinctly what others are taking longer to say. Second, some quotes could not be used because the speaker could be clearly recognised. However, where a useful quote is available but would be likely to identify the speaker the words are paraphrased to uphold confidentiality. Similarly, there are places where just one or two words would reveal the speakers identity so these are replaced with four dots. Three dots are use where, for the sake of brevity, words that do not contribute to the meaning of the quote have been omitted.
To provide an easier flow to the reading of this section on the findings of the study, my main comments have been reserved for the concluding section where various arguments and explanations are developed. In consequence, should the reader come across quotes that surprise them but which appear not to have raised comment, he or she is requested to note them in anticipation of what they may encounter in the concluding section.
3.1.2 The organisation of Section Three
It should be remembered (see 2.1.3) that there were three research questions for this study. The first two, relating to the supervisors course and the nature and quality of supervision provided to the rotatees, will be discussed in this sub section of section three. The rest of section three is devoted to the discussion of the perspectives of the supervisors about the rotation scheme per se.
3.2 Supervisors training for supervision and their supervision of the job rotation scheme nurses
3.2.1 Introduction
Here, two specific elements emerged for the interviews and will be discussed separately below. They are:
- Attendance at the course and preparation for supervision
- Effectiveness of supervision and related issues
3.2.2 Attendance at the three day supervisors’ course and preparation for supervision
At the start of the job rotation scheme there was the opportunity for supervisors to attend a three day, accredited supervisor’s training scheme at Middlesex University. The idea of the supervisors course was a ‘spin off’, which came from a management meeting in one area of one of the Trusts involved, where supervisors were asking ‘what is in it for me’? The original project leader put together a bid to the education consortium at the time, for a small course and he managed to get a small amount of money. It was a one off payment, which allowed two groups to go for training although as it transpired, not many actually turned up.
It is ironic, whilst the supervisors course was set up to satisfy supervisors who had requested ‘something back’ for the extra work they were putting in to help new staff get a degree, few of them actually took up the courses. Even though the course was valued by those who did attend, it may be that most supervisors did not feel that they needed to ‘get something back’ for their work.
3.2.2.1 Attendance
I asked each of the supervisors if they had attended the scheme. Only two had, a third had attended for only one day because of illness and one claimed he had been unable to get a place. Others had discussed supervision with the original project leader at meetings early in the scheme.
3.2.2.2 Value of training
However, some of the following comments demonstrate the value of the training that was provided for those supervising the job rotation scheme nurses whilst other comments suggest that it is highly desirable that such training should be provided for any supervisors involved with future rotation schemes. There are even suggestions that attendance for supervisor training should be obligatory for any prospective supervisor.
3.2.2.3 Useful
I asked Karen if she had attended the supervisors’ course and she provided a very good description of the course saying,
“Yes I did, with Middlesex University. I found it very useful. It was fairly intensive and certainly the assessments were relevant. I found it very useful especially looking into the area of the different styles of conducting supervision. What I recall most clearly is the way to structure supervision and the way to talk to the people in supervision and the principles of supervision and about the supervisees trying to work to the agenda of the supervisor.”
3.2.2.4 Difference between line management supervision and clinical supervision
She went on to explain,
“It was purely clinical on the supervisors’ course. It helped us to make the distinctions between that and management supervision very clear. Clinical supervision should be led by the supervisee and I think the reverse is true in managerial supervision. Managerial is very much led by management.”
3.2.2.5 Confidence, focus and structure
Karen’s next comment raises the possibility that a course on line management supervision should also be provided for any future job rotation scheme of this nature.
Karen added,
“I think it was a very good course. I think that I certainly feel a lot more confidence in giving supervision and I feel that, because of the course, that I’ve had more focus; I’ve had more structure and I feel like supervision is going somewhere and that I’m helping people to progress.”
3.2.2.6 Mandatory
Asked if it was the sort of course that should be compulsory, Karen responded,
“I think that people who provide supervision should be expected… there should be a mandatory expectation that people do a course like that to give supervision. I certainly benefited from it.”
The above comment suggests that there should be a minimum standard of supervision for those on nurse job rotation schemes. However this poses a dilemma. The primary reason for sending job rotation scheme nurses to ‘hard to staff areas’ is that they are short of staff and consequently letting supervisors attend courses is often very difficult. A recommendation of this report is that the planning stage of any future schemes should consider how to ‘square this circle’.
3.2.2.7 An excellent course
Martin said,
“The supervision course with Middlesex University, yes, I did that!”
I asked,
“How useful was that?”
Martin replied,
“It was good! It was good training. I thought it was an excellent course actually. But I think there was a push to get people on it at first and then the impetus ran out so there were only about four or five of us that were trained up in it. I didn’t actually supervise anybody directly. I supervised the supervisors.”
3.2.2.8 Who should attend the supervisors’ course
This response prompted me to ask,
“So, was this unrealistic or realistic? A number of the people who are down as supervisors on the list that I’ve got are like yourself, in that they supervise people who supervise. So, this training for supervision, should it have gone further down the line?”
Martin replied,
“Yeah, yeah! Because definitely, when I was there, it was definitely ward manager level that were on the course and, on the whole, they aren’t the people who do the supervision?”
3.2.2.9 Preparation for supervision
Asked if he had attended the supervision programme for the job rotation scheme nurses, Stuart replied,
“No, no, I didn’t because I’d already done a supervisor course during my previous job. I did the clinical supervision course with the RCN. I’ve used those principles with everyone and I haven’t had any difficulty.”
3.2.2.10 Supervision and formal teaching qualifications
Jane said,
“The people who are supervising the rotation staff nurses would have the ENB 998, you know, so they’re up to date with current practice and changes and things, so I think that’s what’s made it easier and because of the nature of where we work… I mean, we have a good secondary induction package as well, and people are used to inducting new people into areas so I think that helps as well.”
3.2.2.11 Preparation for supervision
I asked Mark what sort of preparation he had had for supervision and questioned whether or not he had attended the three day course for supervision of the rotation nurses. He responded,
“I’ve done the supervision training but I think it was just one day.”
Asked if that had been with the job rotation scheme organiser he replied,
“No, it was the Trust supervision training I’ve done. I’ve done no training for the rotation scheme.”
My question here could be somewhat misleading. In fact there was no training in the Trust itself for the rotation scheme, although there were some information meetings and visits to wards by the original project leader to talk to staff. The three day training was at Middlesex University.
3.2.2.12 Different perspectives
As is the case with Mark, Susan’s somewhat vague response suggests that lines of communication need to be clearer and more effective. I asked her if she had attended the three day course for supervisors of nurses on the job rotation scheme that had been run by Middlesex University and she replied,
“No, I don’t remember a three day course. I remember one of the first times when the whole rotation system was set up and I seem to remember meeting with (the first course coordinator) along with my line managers just talking about what the plans were. You know, about it being a difficult to staff area; about having a regular intake of staff and how they would be rotating through the EMI services.”
3.2.2.13 Conclusion
The course appears to have been advantageous to those who attended it. Looking back over the above quotes it would appear that one of the advantages of the three day supervisors’ course provided by Middlesex University for the D/E nurse job rotation scheme was that it clarified the whole concept of supervision.
Perhaps the nearest comparison here is a factual book which does not necessarily provide the reader with new facts but does draw together the relevant facts in a way that provides a new way of viewing the subject matter. Courses such as the Trust’s one day introduction to supervision and ‘clinical supervision’ courses, as well as the clinical supervision course with the RCN, provide an excellent understanding of specific types of supervision. However, in the next subsection ‘The effectiveness of supervision and related issues’, various supervisors demonstrate their confusion about the overall concept of supervision its various types and models. The evidence provided by Karen and Martin indicates that the job rotation scheme supervisors’ course helped those who attended to clarify the topic for themselves and others.
3.2.3 The effectiveness of supervision and related issues
3.2.3.1 Confusion about need for supervisors’ course
All supervisors stated that supervision is of importance and in some cases they took exceptional strides in providing it in hard to staff areas.
On the other hand, the evidence from supervisors suggests that many are highly confused about the different types of supervision that they provide, the different requirements of supervisees, the available models of supervision, and indeed their own receipt of supervision appears to have been inconsistent. Overall there was a substantial diversity in both the quality and quantity of supervision provided.
3.2.3.2 Confusion
The comments provided below show a confusing picture. Some were quite specific about having given supervision, two claimed that supervision was not working and the rest displayed a tendency, some by implication, to see supervision and mentoring as the same thing.
3.2.3.3 Effectiveness of supervisors
A parallel research study into the quality of the scheme as perceived by a small sample of job rotation nurses taking part in it (Lucock & Coyne August 2006), suggested that supervision was one of the least effective elements of the scheme. This is a fairly common situation on hard to staff wards and some of the supervisors quoted below voiced similar misgivings.
3.2.3.4 Influence of supervisors
Susan explained that she had done quite a lot of supervision. She added,
“There were a couple of us on the wards who were initially supervising for the first cohort and so we’d alternate when students came. I had about three or four students that I’ve supervised.”
3.2.3.5 Mentorship
I then asked Susan if she had been allocated as a supervisor formally or if supervision was just part and parcel of being on the ward. Her response was,
“Yeah, yeah! I was! More often than not it was because they were allocated to me to… not to provide the clinical supervision but to supervise… I suppose more to mentor.”
Pressed further about the type of supervision, she claimed,
“I would say predominantly mentoring, especially with the earlier students. Obviously, when I went into the deputy manager post then it was clinical supervision and managerial supervision that was more of my responsibility.”
3.2.3.6 The connection between work based learning and supervision
Mary had been talking about the rotation nurses’ studies and I asked her if they brought information about those studies back to the ward. She replied,
“Not really! I mean, I imagine if they had specific things they needed to discuss they’d do that with their mentor. But, I mean, they don’t specifically bring things back.”
This prompted me to ask if they all had mentors. Her response was,
“Yes! I mean, the D grades, the new D grades certainly do because they have a preceptor because they might be going on to E grade. But everybody who comes here will get allocated a mentor for the time they’re here.”
3.2.3.7 Supervision is an ongoing nightmare
I asked Mary what supervision was like for the rotation nurses. Her response was one that highlighted the problems that arise from supervision in ‘hard to staff areas’. She replied,
“Supervision is an ongoing nightmare; I think everyone will tell you. I don’t know what other people say. I think everyone struggles with it. I think nurses struggle with it. I think wards struggle with it but it’s there for people. All we get are allocated supervisors. They are given a lot of support and I think the thing is there is a kind of… there is an ongoing network of people being around. It’s hard! What I would say is that they’ve all definitely… all the people I’ve had have definitely been through an appraisal process; they’ve all had appraisals. All the people I’ve had; all the people I’ve had here on the scheme. So they’ve all had that input. Regular supervision is harder but it’s harder for everybody across the service. It’s not just the nurses who are with the rotation scheme. It’s difficult to get up and running in general.”
She added,
“The thing is that I do see it… as a manager, I see it as something I have to push but, you know, I think as well it’s up to junior staff. You know, it’s up to the staff I supervise to come and say to me, ‘Oy, when are you going to supervise me’. It’s a two way thing.”
3.2.3.8 Power and assertion
Mary’s final comment raises the interesting question of what views newly registered nurses have about supervision particularly into relation to power issues such as their rights to support in the workplace.
When supervisors and supervisees are both confused about the purposes of supervision and unaware of various models of supervision, they will be unable to articulate their expectations or monitor the impact of supervision. For these reasons, in this study and the related study of job rotation nurses (Lucock & Coyne, August 2006), many rotatees and supervisors seem to have found it very difficult to be assertive about supervision as a tool for maximising the learning potential within their services.
3.2.3.9 Content of supervision — CPA
When I asked Mark about his experience as a supervisor he replied,
“Well, there have been areas that were addressed but with regards to management issues really. I mean they have clinical knowledge but management stuff, you need to, you know, train them and you learn as you go along. A couple of things I had to impress like arranging meetings and things like that. CPA meetings and admin meetings and stuff like that. Perhaps there could be CPA meetings involving the client, the client’s family, other workers etc in order to check on the overall plan and progress.”
3.2.3.10 Management supervision
Mark’s next response suggests that he undertakes the minimum of supervision required in a post. I questioned the tensions between clinical supervision, line management supervision and mentoring. Mark said,
“Well, I do management supervision here with the next senior… the next level down. We used to do clinical supervision but when you do management supervision you address all the issues with regards to their performance, according to their job description. I go by the job description; go through the job description and, you know, highlight areas where they will be doing things and find out why things aren’t happening or why they find it difficult to perform at a certain standard. That’s how I do the supervision.”
In relation to mentoring, Mark said,
“When they first come in they have mentors, because they are all D grade staff nurses when they came in. So, I would delegate an E grade staff nurse as a mentor and then when I… I get feed back from the person who’s mentoring them and then I would do the upgrade interviews and once they’ve been upgraded to E grade, I supervise them, because they’re at the same level.”
3.2.3.11 Content of supervision — worries
Asked about the nature of the supervision given, Ursula said,
“I meet with them on occasions but I always talk to them every day and support them that way and then I tell them that if they ever need major supervision; that they’re worried about something, you know, outside of work time or something like that.”
Here, Ursula has suggested two more possible types of supervision, ad hoc and ‘if required’, both of which could be useful on busy, hard to staff wards.
3.2.3.12 Peer supervision at university
Ursula then went on to make an interesting comment about the possibility of peer supervision emanating from the university course. She said,
“But I’ve always told them that what they should do is get together in their own group. If there’s anything that they need to discuss, discuss it then and then come back. If there’s anything they need from us, to ask, if there’s any clinical procedure that they have never seen.”
I asked,
“And do they do that?”
Ursula responded,
“They do, yes.”
3.2.3.13 Content of supervision — reflective
Stuart said,
“I use the John’s model of clinical supervision and I would go through an example. We go through that, just sticking to that one incident and you’d be surprised at how much change of practice you can bring along. And sometimes people don’t realise that by a little incident of saying no to a patient the consequences it has for the professional ethic.”
3.2.3.14 Supporting course work
Stuart clearly had a wider concept of supervision. He commented,
“And sometimes I have to say, ‘Hello, I’m here to supervise you. I will look at your essay.’ Somehow you can’t help it. Because I have been studying myself it makes it easier. And I think for me it has been easier because of my experience so I am able to demonstrate bad experiences. ‘These things have happened’ although sometimes you have to use the positive point of view.”
3.2.3.15 Experienced at facilitating learning
I asked if he thought that the supervision has worked well and he answered,
“It has worked well. I think it’s experience! To me, a supervisor is an experienced person. They are able to facilitate the learning better. That’s a personal opinion.”
3.2.3.16 Supervision model
Brian said,
“I supervised people who were on the rotation although our G Grades on the team they could have done a bit but they all had heavy case loads. And because I had a smaller case load because I was managing the CPNs, that’s the reason why I supervised the rotations nurses. I used Proctor’s model. They would come to me and say, ‘Oh well you know, I need this for my forms, I need to go and do that’. And it was fine because everything was done through negotiation. I’ve always used Proctor’s model because I find it the most helpful one.”
Stuart had spoken about using John’s model of supervision whilst Brian said he used Proctor’s model. Whilst Proctor’s model is specifically a model for clinical supervision, John’s is a reflective model for clinical practice. This raises the question as to whether there should be one model of clinical supervision for job rotation scheme nurses.
3.2.3.17 Clear rotatee expectations are helpful
Jane had not been in her post long enough to have attended the supervisors’ course for the rotation scheme. I asked if she felt that that put her at a disadvantage. Her response was,
“There haven’t been any problems but I think the students are quite clear about what they’re meant to gain from each placement. So I think if they are working closely with the supervisor then that should be met.”
Jane raises a very important point. In any situation but particularly where there is a steady turn over of staff, it is important that the students have a very clear idea of the aims and objectives of supervision in order to help the supervisors to assist them.
3.2.3.18 Supervisors’ experience of supervision
I asked Harry,
“What is your experience of supervision? Are you able to give clinical supervision?”
Harry’s response was,
“I think the system is a bit inconsistent in clinical supervision in itself regardless of whether you are on rotation or whether you are current staff. So, on the rotations scheme I don’t think there is consistence. I think it is lacking in both clinical supervision and management supervision.”
3.2.3.19 Trust audit of supervision
I asked if that was because he worked on an acute ward and he replied,
“I think it’s partly because it’s acute but also, although there is insistence on the importance of it, in my experience, it reflects a lot about what you can get. I think it’s probably the system itself. I was looking at one of the audits that was done Trust wide a couple of months ago on supervision and you can see that it’s not just this hospital. It’s across the Trust. And you can see that people sometimes haven’t had supervision for a year in some places. I think it’s more at a junior level rather than at a management level. Managers will have the supervision but it’s more down the chain that people feel that they are having inconsistency.”
3.2.3.20 Time as a scarce management resource
To this, I responded,
“Do you think that’s because of time or because people don’t value it?”
Harry replied,
“I think time is probably an excuse for it. If you want to do something you find time. Management is good at criticising and pointing at people but when it comes to looking at how to support people getting supervision they don’t do it.”
3.2.3.21 Improving quality of supervision generally
Karen provided useful leadership ideas about improving quality, and about taking the initiative beyond the current project, arguing,
“I also supervise other G Grade nurses at the moment and I supervise GP liaison nurses as well so I supervise a range of nurses.”
She added,
“The supervisors’ course was purely for the job rotation scheme but I think that it needn’t necessarily be purely for the rotation scheme. I think it would be a good idea to open it up to whoever. I think that there’s been a lot of focus on supervision in the Trust and in this area and other areas of the Trust. It’s well established and people do get supervision. What hasn’t really been looked at is the quality of that supervision. And I think we need to look at that and we need to firm that up a bit.”
3.2.3.22 The need to clarify and enhance supervision
Looking back on this sub section we gain a very mixed picture. Susan is clearly aware of the different forms of supervision but ‘blurs the edges’ by including them all under one umbrella. Mary is also aware of the differences but there is a sense that the driving force, even for mentoring, is the appraisal system. Ursula is clearly aware of the need for supervision but is content to provide it on an ad hoc basis ‘as required’ whilst Harry’s concern about the general state of supervision tells us nothing about his own actions. Similarly, Stuart, Brian and Jane all appeared to give regular supervision but did not comment on its form.
Mark, on the other hand appears to be ambiguous about supervision. One gains the impression that the job rotation scheme nurses are assumed to already possess the necessary clinical skills but will need supervision to gain managerial skills. Furthermore he seems not to be aware of the long standing acceptance that clinical and managerial supervision are best provided separately and by different people.
From some of the quotes in 3.2.3 above we encountered the confusion that is supervision. It would seem probable that, for many in a supervisory position, it is difficult to use this ‘tool’ to help each other, as each party has a widely different understanding, misunderstanding, or even no understanding of what the term means. Clearly that is not the whole picture. From the accompanying study it is clear some rotatees had exceptional supervision in the workplace and they all experienced it from the university.
3.2.3.23 Conclusion
All supervisors stated that supervision is of importance. This study provides evidence about a great deal of confusion about supervision, and about the quantity of supervision provided. This led to a highly diverse picture of the quality of supervision provided and received. It would seem that there is extensive scope for improvement to the effectiveness and efficiency of supervision as a learning tool in both of these organisations.
3.3 — Advantages and disadvantages of the scheme for colleagues at work