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Helpful aspects of Work Discussions Experienced By Hospice Nurses in Group Supervision Meetings Dr Alun Jones Also: Adult Research Psychotherapist Reprinted by permission of the author Later when you face old age and its natural conclusion Introduction This paper describes the setting up of a small clinical supervision group consisting of five hospice nurses. The study illustrates ways in which mental health nurses might contribute to group work and palliative care, research, education and professional practice more generally. The discussion explains aspects of the study and discusses issues only related to the project. Knowing something about the ways in which clinical supervision can help nurses seems important. We need to know how it works best in order to effectively meet the needs of nurses and enhance clinical practice. Hyrkas et al (1999) suggested that although clinical supervision is debated widely in the nursing literature, studies carried out to date have failed to show how supervision benefits clinical practice. The authors reviewed literature related to clinical supervision internationally, and argue that nurses share different views as to goals of clinical supervision. Hyrkas et al (1999) also noted that we know little of how clinical supervision should be conducted. The Need for an Environment of Support and Learning Considered support for workers who provide palliative care seems consequential to the quality of care provided. Several documents published in the United Kingdom (Department of Health, 1993; Department of Health, 1994; UKCC, 1996; NMC, 2003) recommend clinical supervision as means of enhancing the delivery of health care along with support and continued education for nurses. Work discussions in supervision could help nurses to understand better the complexities of nursing practice. A Brief Outline of the Research Study What follows is an outline of a hospice research study completed several years ago. The project was designed in such a way as to encompass two important areas of professional practice and to attempt to make links between them. Namely, supportive supervision of clinical practice and addressing patients concerns efficiently. The design of the study acknowledged the demands made on nurses through daily contact with people suffering serious illness and the support they offer to families. Permission to carry out the study was granted by an Ethics Committee, a Hospice Management Team and the nurses involved. Other detailed accounts of this study are reported elsewhere (Jones, 2003). We met together in the nurses’ workplace one and a half hours weekly for twelve weeks. Issues concerning professional practice were examined with the help of a researcher (AJ) who acted as the group leader. At the end of the group’s life, nurses were asked by the researcher to complete a questionnaire related to the workplace and twelve identified beneficial factors derived from the group experience (Yalom, 1975; Yalom, 1995). Two weeks later, the hospice nurses were interviewed in a group format and asked to consider the reasons for their choice of answers. The data revealed that collectively - Interpersonal Learning (Output), Identification, Catharsis, Family re-enactment, Group Cohesiveness and Self-understanding were experienced by the hospice nurses as the most helpful factors to the group. Existential factors, Guidance, Universality, Interpersonal Learning (Input), Instillation of Hope and Altruism were identified as less important (Appendix 1). Variations in individual responses showed different ways in which a group might meet the needs of its members. The study concludes with the suggestion that clinical supervision, conducted as work discussion groups, can offer nurses the means to compose, regulate and plan their interactions with themselves and others. How Did the Study Work? Essentially, there were two strands woven through this study. The first concerned a small supervision group. Meetings took place for one and a half hours each week over a period of twelve weeks. Hospice nurses chose to join the group following a meeting with the researcher. Supervision helped nurses to consider aspects of their professional practice and contribute to their colleagues’ practice through listening, thinking about issues and offering opinions. The focus was on collaborative learning, support and the management of care. The second strand was concerned with developing nurses’ competence as listeners and so providers of psychological care. Together we attempted to discover if opportunities offered through supervised practice helped nurses to be more responsive to the concerns of patients and their families and their own necessities along with their colleagues? Evaluating Outcomes? We evaluated the benefits of group supervised practice in a number of ways. First, we accessed changes over the period of supervision by means of a questionnaire and then conducting a collective interview with group members. This part of the evaluation was carried out sensitively and anonymously. The study did not so much appraise individuals but a group format of clinical supervision as an effective learning tool and support for hospice nurses in their day-to-day clinical practice. The Group This study was conducted with a small group of committed and motivated hospice nurses. The group enjoyed excellent working facilities and the encouragement of an enthusiastic and supportive nurse manager. The study suggests however that working with serious illness, death and bereavement is demanding of nurses emotionally. Nurses in this group shared clinical vignettes, which reflected feelings of loss, shame, fear and saturation with issues concerning serious illness, dying and bereavement. Group members also struggled to make sense of complex human dynamics, which influenced their relationships with both client groups and fellow professionals. Attempts to separate personal concerns from professional issues were, as well a common and recurring theme throughout he group’s life. The group nonetheless, gave members an experience through which the difficulties concerned with hospice work could be contained and anxieties moderated. The group also offered opportunities for nurses to affirm each other and think about all that was good about their professional practice and their own contributions. The group experience, while initially anxiety provoking presented each nurse with chances to give and look to others for support. Group members could feel less isolated. The nurses in this study were commanding of respect. Their professional commitment and integrity was praiseworthy showing at all times concern for their work and their colleagues. Even during periods of negative feelings the nurses who formed this group wrestled with the appropriateness of their thoughts and behaviours and wanted to carry out all aspects of work to the best of their abilities. The hospice nurses in many instances showed advanced clinical knowledge and expertise and an unwavering sense of humanity in the face of recurrent challenges and this may be concerned with the personalities of nurses attracted to this type of work. The nurses frequently saw the order of the world as turned upside down yet they cared deeply about people whose deaths were untimely and without comfort. Sometimes the people entrusted to their care were colleagues and so invoking powerful processes of identification. Notions of a timely and consummate end to life, as are reflected in the poem, which prefaces this discussion, were challenged almost daily and seemingly influenced nurses' relationships with themselves, colleagues, and families. Moreover, working with issues concerning serious illness enhanced a sense of living in an uncertain world. While this could reasonably be considered a human given, nurses in this study seemed unable to find relief from the worries of existence. Bertman (1991) argues that in Western society, notions of the perfect death encompass ideas of:
As Bertman suggests, a death, which is both romantic and aesthetic and where communications are regulated and controlled, might rarely be achievable. Yet, this small study suggested, hospice nurses sometimes feel that they are required to facilitate the consummate end to life. Subsequently, they become caught up in what the North American poet Anne Sexton referred to in her poem courage as a 'fever of love'. That is to say death should always occur as a loving, peaceful, calm and a timely and dignified event and nurses should feel compassion for all in their care without personal consequences. Work discussions offer opportunities to regulate responses and act appropriately. In the UK, Eve Richards, Chief Executive for the National Council for Hospice and Specialist Palliative Care Services, recently stated that:
This small explorative study suggested that clinical supervision is a potent format for exploring issues concerning professional practice. Yet it infers that the provision of care to patients with serious illness entails what the North American psychologist Carl Rogers (1980) referred to as being person-centred rather than patient-centred. This more appropriately encompasses the responses and overall personhood of those responsible for providing care as well as the inter-subjective nature of care provision. Clinical supervision in this study allowed nurses to learn, from each other and about themselves with reference to their working environment. It also gave all nurses opportunities to offer support, and recognise how others value them as fellow workers. Hospice nurses, to begin with tentatively, shared their experiences of professional practice. However, as they became more familiar with group work and began to feel safer with their fellow group members and facilitator discussion became more vibrant with spontaneous contributions more forthcoming. The nurses frequently showed excellence in the delivery of care to vulnerable groups of people and demonstrated appropriate concern for the well being of fellow workers. The opportunities to talk and listen about professional practice seemed to heighten confidence and increase empathy towards each other and other professional groups. The clinical supervision group also helped to moderate concerns and anxiety related to the sensitive yet demanding nature of much of hospice nurses’ work. Clinical supervision therefore granted a way to ensure some measure of safety and ensure the quality of care delivery. Clinical supervision can offer occasions for nurses to face themselves and others candidly in relation to their work. A supervisor can be supportive in recognizing that psychological defenses are necessary for nurses to cope and survive the demands of hospice work. Hospice nurses can then be helped to understand personal responses, which whenever necessary could be restructured, refined or calibrated them to show sensitivity and compassion to themselves and others. This small study suggested that supervision could provide hospice nurses with time for contemplative, strategic and anticipatory ways of thinking. Nurses can, together and with support, witness the difficulties and challenges of being with others authentically at times of pain. Notwithstanding potential benefits, this study suggests that, initially group work could arouse anxiety in all participants and preparation and support are required for the group leader and group members. Carefully chosen membership is also considered important to the safety of members and successes of the group. Furthermore, issues of gender and ethnicity should be considered important to the safety and sensitivity of the group members. So what have we learnt now the Project Is Completed? The study showed that with thought, it is possible to establish group supervision for hospice nurses and identify the potential benefits to be derived from clinical supervision. The nurses that formed this group were each committed health practitioners. They showed ability to address with sensitivity, complex and frequently poignant issues concerning serious illness dying and bereavement. The facilities on hand were excellent and the empathic support from the hospice management team formed a feature of this work. Clinical supervision, or other forms of work discussions, should continue to support the work of hospice nurses and other workers. This study suggests that it should form a part of working time, which is protected from the intrusion of other responsibilities. Hospice nurses should undertake further education and training, learning how to become supervisors and supervised. Perhaps hospices might develop a directory of supervisors and so nurses could supervise individuals and small groups outside their own work environment. Limitations The limitations of a small study include a single group, in part, qualitative methods of research and a single male facilitator who also acted as a researcher. Consequently, recommendations cannot be made, as the findings might not relate to all hospice nurses equally. Inferences may be drawn from the study however, and could offer guidance regarding how clinical supervision might benefit hospice nurses and all that are concerned with the provision of care to the seriously ill and their families. Hospice care is rooted in a fundamental principle that the seriously ill, the dying and the bereaved require an environment characterized by dignity, security and calm. Work discussions in clinical supervision could go some way to offering similar conditions to hospice nurses. In turn, nurses may be better able sustain periods of uncertainty and ambiguity, recognize personal and professional influences on care and so be more able to meet, sensitively, the needs of vulnerable patients and families. References Department of Health (1993) A Vision for the Future: The Nursing, Midwifery and Health Visiting Contribution to Health and Health Care. HMSO, London. Department of Health (1994) Clinical supervision; for the nursing and health visiting professions. CNO Professional letter 94 (5) 11th February, London. Hyrkas. K., Koivula. M. & Paunomon, M. (1999) Clinical supervision in Nursing research in the 1990s – current state of concepts, theory and research. Journal of Nursing Management.7, 177-187 Jones, A. (2003) Some benefits experienced by hospice nurses from group clinical supervision. European Journal of Cancer Care. 12: 234-272 Nursing and Midwifery Council (2003) Clinical Supervision. www.nmc-uk.org/cms/content/Advice/Clinical Supervision. Richards, E. (2001) National Council for Hospice and Palliative Care Services: Palliative Care Now A Priority. Press Release. www.hospice-spc-council.org.uk Rogers, C. (1980) A Way Of Being. Houghton Mifflen, Boston Yalom, I.V. (1975) The Theory and Practice of Group Psychotherapy, Basic Books, New York. Yalom, I.V. (1995) The Theory and Practice of Group Psychotherapy. Basic Books, New York. Fourth Edition United Kingdom Central Council for Nursing Midwifery and Health Visiting (1996) Clinical Supervision: Guidelines for Practice. UKCC, London Copy Right 2004 Alun Jones return to top
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