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   Table of Contents      
Year : 2016  |  Volume : 21  |  Issue : 1  |  Page : 63-70

Requirements for nurse supervisor training: A qualitative content analysis

Department of Nursing, Nursing and Midwifery School, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran

Date of Web Publication25-Jan-2016

Correspondence Address:
Tahere Salimi
Department of Nursing and Midwifery, Nursing and Midwifery School, Shahid Sadoughi University of Medical Sciences and Health Services, Boali St, Safaeyee, Yazd
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Source of Support: Shaheed Sadoughi University of Medical Sciences and Health Services, Conflict of Interest: None

DOI: 10.4103/1735-9066.174760

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Background: Supervisors should have certain characteristics and adequate preparation for their roles. Yet, there are no well-educated experts knowing about the supervisor's role and responsibilities and how to train them. So, this research was conducted with the purpose of finding the factors affecting nursing supervisor training.
Materials and Methods: This research is an inductive content analysis. Participants were 25 in number, consisting of nurses and supervisors in Shahid Sadoughi University hospitals. The participants were chosen by a purposive sampling method. Data collection was done by semi-structured interviews and reviewing documents. Data were analyzed using conventional content analysis.
Results: Findings included two main themes: Firstly, establishment of a supervisory infrastructure that includes “making the appointments and retention of supervisors, clarifying the duties and authority of supervisor, developing supervisory culture, specializing supervision, and conducting practice-based training” and secondly, comprehensive supervisory competencies that include “acquiring scientific, managing, communicative, professional, ethical, pedagogical, and supporting adequacy.”
Conclusions: Clinical supervisor has a major role in ensuring the quality of nursing care. This leads to improvements in patient care and nurses' personal and professional development. So, it is necessary that for effective supervision in nursing, first an infrastructure is provided for supervision and then the comprehensive competency of a supervisor is enhanced to apply effective supervision.

Keywords: Clinical supervisor, education, inductive content analysis, qualitative research, supervisory nursing, training

How to cite this article:
Dehghani K, Nasiriani K, Salimi T. Requirements for nurse supervisor training: A qualitative content analysis. Iranian J Nursing Midwifery Res 2016;21:63-70

How to cite this URL:
Dehghani K, Nasiriani K, Salimi T. Requirements for nurse supervisor training: A qualitative content analysis. Iranian J Nursing Midwifery Res [serial online] 2016 [cited 2023 Mar 23];21:63-70. Available from: https://www.ijnmrjournal.net/text.asp?2016/21/1/63/174760

  Introduction Top

Supervision is observation of staffs during work and formal guidance on how to do so with each of them.[1] In health care organizations, as protecting life and human health and nullifying clients' needs are the main goals and much complexity has been observed in them than in other organizations, supervision becomes more necessary and its importance becomes obvious.[2]

Supervision has been introduced as clinical supervision in health care organizations. The Department of Health's clinical supervision has been defined as “a formal process for supporting, training, and professional learning.” It provides a safe and confidential environment for the staff to reflect on and discuss their work, which enhances their awareness and clinical skills and leads to improved competency. The supervisee should accept responsibility for their performance.[3],[4] In nursing, clinical supervision is a process in which between two or more professionals (novice nurse and practitioner nurse), the focus is to provide a basis for monitoring, assessing, examining practice and receiving feedback at work, which could lead to the development of professional skills.[5],[6]

Clinical supervision is done in hospitals by clinical supervisors. Clinical supervisor is a nurse who has the responsibility to directly supervise nursing services and helps in reaching the organization's goals with supporting and expanding knowledge, skills, commitment, and performance.[7] Supervision is helpful in identification of clinical problems and supervisor may help nurses in the admission of new role.[8] Experts and fully trained clinical supervisor/s can inform nurses what and when to do, while supervising, and bring development to the organization; they support and strengthen the supervised nurse and maintain and enhance the quality of care.[9]

Supervisors should meet specific criteria and have adequate preparation for their role.[1] Organizations and/or employers are bound to empower supervisor in clinical supervision in order to provide qualitative monitoring services.[10] According to Butterworth et al., all nurses must be trained in clinical supervision.[11] The Department of Health in England also recommended familiarity with clinical supervision in a professional training course.[12] While there are few studies on training a supervisor, expanding supervisory standards, and evaluation of the supervisory process, most of them have been used in counseling, psychotherapy, and other mental health disciplines.[13]

Although training and educating resources are restricted, there is willingness and attention in training and educating nurses in clinical supervision.[14] There are problems in the development and establishment of clinical supervision.[15] Owing to lack of resources for education and training, as well as insufficient support from supervisors, clinical supervision has not yet been established in many countries.[16]

In this regard, Sloan mentioned that 65% of the supervisors believe that they do not have enough readiness for supervisory role.[17] In Iran, Azimian writes that nursing managers have high educational need to guarantee the quality of care.[18] Baghae et al. state that nurse managers tend to improve the knowledge, attitude, and performance management.[19] Therefore, there is not enough knowledge about the role and the different responsibilities of a clinical supervisor and their way of training.[20]

On the other hand, the concept and usage of clinical supervision are found to be different in various countries.[21],[22],[23] These conceptual differences are assumed to have an effect on the goal, meaning, nature, and duration of relationships, the role of supervisor, and supervisee (such as experience, education, and position in the organization).[24],[25] Further research is needed to know about the meaning of this concept in any culture. Clinical supervision should be cleared within a particular context (culture).[21],[22],[23]

Consequently, regarding the unique feature of Iranian culture and paying attention to supervisor's and supervised experience in the supervision, qualitative research methods were used in this study to understand the clinical supervision phenomenon. The qualitative research is a tool for understanding and deeply discovering the inherent complexity of a phenomenon that reveals various aspects of the subject.[26] Qualitative research has been found to be an appropriate approach for recognizing unknown dimensions of the clinical supervision phenomenon, and has been used in this research to explore the factors that influence the training of nursing supervisor.

  Materials and Methods Top

The role of a supervisor is affected by various factors and understanding these factors needs consideration of experiments, beliefs, and values of supervisors and supervised nurses. As there is not adequate information in this regard, researchers chose qualitative research. The method used in this research is qualitative content analysis.

Content analysis is a widely used qualitative research technique which is potentially one of the most important techniques in social science research that analyzes data in order to identify them. This method is also used in nursing research and education to collect a wide variety of data and to have deep interpretation.

This study was conducted from 2010 to 2012. It consisted of 25 participants (including 10 nurses, 9 supervisors, 2 matrons, and 4 head nurses) employed in Yazd's hospitals. Participants willing to participate and possessing the ability to describe their experiments about clinical supervision were chosen by purposive sampling method. In-depth and semi-structured interviews were appropriately used regarding qualitative research tenets. Some questions in the interview guide are, “How can a nurse become a supervisor?” and “Talk about a supervisory shift.” Also, some existing documents such as supervisory notes were analyzed. Before each interview, the participants were informed of the approximate length of the interview and all the interviews had been conducted by prior arrangement and written right after the interview within the first 24 h; therefore, they could be used as main data. Interview duration was a minimum of 20 min and a maximum of 130 min, and interviews were continued till data saturation was reached. Since the environment of qualitative study is the real arena, i.e., the real place at which the process occurs, the hospital was chosen for the place of this research. Conventional content analysis method was used to analyze data; the content of all interviews and supervisory reports were collected and through inductive process, the coding was analyzed.

The four main steps of content analysis were used with some adjustments in order to find the master codes. After reading them several times, the first stage of coding process was started through identifying and highlighting sentences and paragraphs of the analyzing unit. According to a prior decision, both explicit and implicit contents were analyzed.

A master code was given to each analyzing unit and subcodes were extracted. In the second stage of coding, superior codes with same meaning were classified. After classification, they were interpreted by meaningful conceptual model. The relationship between categories had been identified and themes were apparent. Themes were extracted in order to validate, member check, and data sets were separately analyzed to derive the source of supporting evidence.

Different methods like persistent observation, allocating sufficient time for collecting data, and good communication with participants in order to increase the trustworthiness, credibility, and confirmability of the data have been used. In addition, member check has been used to review the interview text and themes extracted from the interviews. Also, the accuracy of the coding process and content was confirmed by two external observers, who were skilled colleagues.

Ethical considerations

Research ethics had been observed in the study in obtaining informed consent, ensuring participants' privacy, data confidentiality, the right to withdraw from the study anytime they wanted, and the right to ask for recording interviews and the text of it by the participants.

  Results Top

Analysis of data showed that there were two themes in order to train a nurse as a supervisor: Establishment of supervisory infrastructure and comprehensive supervisory competencies. The establishment of supervisory infrastructure included “making the appointments and retention of supervisors, clarifying the duties and authority of supervisor, developing supervisory culture, specializing supervision, conducting practice-based training” and comprehensive supervisory competencies included “acquiring scientific adequacy, acquiring managing adequacy, acquiring communicative adequacy, acquiring professional and ethical adequacy, and acquiring pedagogical and supporting adequacy” [Figure 1].
Figure 1: A summary of themes and categories of nurse supervisor training

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The first subcategory is “making the appointments and retention of supervisors.” The experiences of the participants showed that selecting the supervisor was done based on several criteria and some were vague; most nurses were not aware of supervisors' criteria and the legal requirements in selecting and monitoring supervisor were not clear. Moreover, the retention period was uncertain for supervision. One of the participants said in this regard:

“Supervisors are not selected really according to the reception staff, who do not have merit and competence and it is not important that who he is, where he is from, what his literacy is, what his experiences are, which part did he work in, can he respect the staff or not.” (Supervisor 16).

Are supervisors evaluated? And no one sees how do they work?” (Head nurse 4).

The next subcategory is “clarifying the duties and authority of a supervisor.” Supervisors are not aware of duties, authority and responsibility. Their duties' explanations do not have written justification. The task range of supervisor and supervisee is not clear. Also, the purposes of supervision are unclear and some nurses believe the reason of not doing some duties by supervisors is the lack of explanation for the task and that the supervisors' performance in hospital is not clear supervisor's role in hospital, it is only on individual attendance and absence. Because there is no clear task explanation, each supervisor has different routines and processes. The supervised believe that some supervisors' shift is convenient and some are with objection and severity. The supervisor's authority is ambiguous, and the supervisor does not have enough authority or as much authority as his responsibilities. Due to lack of sufficient authority, to make the smallest things and decisions, they should consult with their superior. Regarding this, the participants said thus:

Now, our task explanations are not written, it's oral.” (Supervisor 13).

Supervisors' task explanations are not clear and you do not know what should you do or not at all.” (Supervisor 23).

Our authorities are narrow, we do not have enough authority and sometime we have to consult with the headmaster or hospital principle by plan and it wastes our time and energy to find them and speak with them and maybe there is not enough time for all of those.” (Supervisor 8).

I have to have many and sufficient authorities to work, but it is not like this.” (Supervisor 7).

Most of the times we speak and coordinate with headmaster and matron to not to get in trouble tomorrow.” (Supervisor 8).

The other subcategory is “developing supervisory culture.” As in many countries clinical supervision is an interpersonal process, an activity that brings skilled supervisors by supporting which enables less-experienced nurses to develop knowledge and competence, as increase understanding of professional issues. But according to our respondents' experience, our supervisory process has no meaning. In our country, supervisor provides administrative and disciplinary approach in supervision, rather than training approach. This situation does not provide effective supervision, which requires the establishment of an appropriate supervisory culture. Participants said thus:

Only some (supervisor) comes, to mention the staff, troubleshooting personnel, to fill report, to have two lines report tomorrow, someone does say that has not gone to the hospital ward for supervising.” (Nurse 6).

Another subcategory is “specializing supervision.” Based on the participants' views, the nature of supervision as a construct is complex and multidimensional (such as the complexity of the treatment, health care, environment). Supervision is very situational and unexpected. There is diversity in the task and procedure. Supervisors should monitor all events in the hospital. These views showed that for better supervision, each supervisor works out a particular area or a specific unit. Participants said about this as follows:

One of the important things I learned this year from the work of a supervisor, the

relevant unit of the hospital should be supervised by a supervisor, for example, surgical unit should be supervised by a supervisor, medical unit should be supervised by another supervisor, and it is good to know what

each unit is, how it works. ”(Supervisor 23).

The other subcategory is “conducting practice-based training.” All participants were urged to undergo supervisor training. Supervisors believe that appropriate teaching methods should be used to improve knowledge, skills, abilities, and attitudes. Regarding this, participants said as follows:

None of us have scientific, pedagogical, managing education regarding supervision and we want to do well inherently. I do not think that there is a supervisor with management education.” (Supervisor 8)

“Very often we have nursing classes such as nursing management, but it is not helpful. We need practical training and undergo job training. Our training should be based on work experiences. What we are taught must be put into practice and skills so that we can do our job well.” (Supervisor 16).

One of the subcategories is “acquiring scientific adequacy.” Based on the experience of participants, the supervisors have lack of basic and specialized knowledge and clinical skills. Most of the supervisors are staffs with high working records. Clinical skill is especially poor. Some of them do not even have enough clinical skill and knowledge in their history because of the shortage of clinical records. Usually, for various reasons, supervisors do not have enough training and learning and this is the cause that supervisors do not have adequate and appropriate supervision of all clinical areas. But based on supervisors' understanding, knowledge and experience are very important in supervision [Table 1]. Participants said in this regard as follows:
Table 1: Process of content analysis illustrated by examples of code, subcategories, and categories about acquisition of scientific competence

Click here to view

For example, Mrs. X of whom I do not want to talk at her back, comes to NICU (Neonatal Intensive Care Unit) and I can swear does not know anything. When we do the gavages, we elevate the head of the bed so the kid won't aspirate, but supervisors ask why? I'm sure if I say turn the incubator on and adjust it, she can't.” (Nurse 3).

The other subcategory is “acquiring managing adequacy.” According to nurses' and supervisors' understanding, the most important requirement for supervisory is their management, although the supervisors say they do not have management education and their performance is empirical, tentative, and imitative and there is no innovation. However, according to statements from supervisors, they need to identify, state, and solve the problem for planning, decision-making, and knowing how to deal with conflict. Participants said in this regard:

They have to manage an administrative training class for us to get to know with management rules. We perform something natural or tentative, but we do not know if it is right or not.” (Supervisor 19).

Sometimes it is good to know what you should do legally, the thing that is administrating; we have to get informed about rules, some information about staffing employees. Some classes about hospital decisions that I should be informed before.” (Supervisor 5).

”We should become familiar with the administrative rules; we need to learn management skills such as solving and conflict resolution. There are a few things we have on our own experience that

we do not know is true or not.” (Supervisor 19).

The other category includes “acquiring communicative adequacy.” Based on the experiences of participants in the study, this subcategory means that it requires appropriate behavior between the supervisor and the supervisee. Also, supervisor needs capabilities such as negotiation, coordination, collaboration, and facilitating teamwork.

”Supervisors should have learned how to deal with staff, what to say to everyone, how to behave that way, not to offend staff and not damage patients”.(Nurse 1).

The other subcategory is “acquiring professional and ethical adequacy.” Therefore, in this study, from the perspective of the participants, the supervision requirements are ethics, commitment, compliance with laws, rules, and regulations, acting in accordance with the conditions, maintaining privacy and confidentiality, seriousness of the work, stability of behavior and stability of decision making at work, the effort and perseverance, and behave justly. The supervisor needs to participate in educational programs to improve their knowledge and performance.

However, many times, we do not see some supervisor participate in training classes. In your opinion, supervisors, do you not need training class? Supervisors are required to get training certificates for promoting employment. What's a certificate? How do you evaluate employees at year end? It seems certificates would be issued.” (Head nurse 2).

”One time my husband was coming into the hospital and went to the supervisor. I will not let my wife go to work tonight. He had an awful temper with supervisor, He had shouted, but the supervisor never spoke about it with me and nowhere she said about it.” (Nurse 24).

The last subcategory is “acquiring pedagogical and supporting adequacy.” Based on the participants' views, the educational role is to provide scientific guidance to supervisee. It is necessary that rather than simply report problems, simultaneously education reforms are applied. Supervisors also need to offer support to supervisee or play a supporting role so as to provide empathy, take part in active listening, give confidence and assurance. The supervisor must, with respect to the competencies and capabilities of the personnel under their supervision, offer support to supervisee in times of need.

Some of the supervisors, for example, if staff does not write correct nursing documentation, they teach staff how to write correctly, whereas some supervisors will only have to report to the directors. (Nurse 9).

For example, supervisor Z, I often speak with him and say to him, 'our department is very busy, the number of patients is high, we cannot do all the work.' For example, once between me and a medical student, there was a

conflict to accompany the patient to the computed tomographic scanner to another hospital; the medical student said that I should go, but I said to the student, 'you should go to the hospital with the patient under the hospital laws.' The issue was brought to the supervisor; the supervisor said medical student should go.” (Nurse 2).

  Discussion Top

Clinical supervisor has a very important role in ensuring the quality of care, and improves patient care and follows personal professional development of staff nurses. According to the experiences of participants in this study, both the themes, i.e. establishing supervisory infrastructure and comprehensive supervisory competencies, affected supervisor training.

Due to the special role of supervisors in hospitals, it is very important that the process of training and preparation be done for supervisors. Grealish and Carrall found that supervisors do not have enough preparation for their role and felt that their supervising is done non-intelligently.[27] Eriksson and Fagerberg, while describing the experiences of geriatric nursing supervisor, mention that the results refer to the need for improving the abilities and skills of supervisors. Tembani and Strümpher observed that lack of proper monitoring had been reported in a number of clinics. Thus, formal and informal preparation of clinical supervisors is important for their supervisory role.[28] Hore et al. report that supervisors should be trained in the process of supervision and provided time and resources to manage it.[29] Pillay and Menshaly showed found that some supervisors were not prepared for their role and responsibilities and there is a need for increasing the supervisors' competence.[30]

Based on the findings of the research, establishment of supervisory infrastructure, making the appointments and retention of supervisors, clarifying the duties and authority of supervisor, developing supervisory culture, specializing supervision, and conducting practice-based training should be done for training supervisors.

Hore et al. showed that for the supervisor and supervisee, the expectation of supervision should be clear and barriers to clinical supervision are conflicting demands of the hospital and the supervised to the supervisor and the lack of clarity of rules.[29] Kilmenster et al. mention that the supervision should be structured and carried out regularly according to the program. Content of supervision should be agreed upon and the aims specified before beginning supervision.[31] Results of Knudsen et al.'s study also showed the quality of clinical supervision is strongly dependent on the perception of autonomy or authority at work.[32]

The findings this study and the studies published by another researcher determined the importance of supervision goals, clarified the roles and responsibilities, and delegated responsibilities to the supervisor. For the implementation of effective supervision, it is very important to give attention to organizational culture, and the organizational climate and atmosphere should be prepared in compliance with the culture of supervision. Gonge and Buus found that characteristics of the work environment, including organizational status, shift work, and environmental factors in the workplace affect the outcome of clinical supervision.

Based on the findings, supervisors have to acquiring scientific, managing, communicative, professional, ethical, pedagogical, and supporting adequacy. Supervisors need enough clinical and administrative knowledge and skills for their roles and it should be considered in their training and preparation. Arvidsson and Fridlund write that the factors that affect supervisors' competence have both personal dimensions including supervisor's behavior in dealing with nurses and professional dimensions included creating a safe place to learn and facilitating consideration.[33] Kilmenster et al. reported that the things that are necessary to train supervisors include the skill of advising and guiding, supervising, feedback, and interpersonal communication skills.[31]

Sivan et al., state that the relationship between supervisor and supervisee at interpersonal level affects the quality of the supervision process.[34] Brunetto et al., showed that nurse–supervisor relationship affects the professional commitment on the hospital and the intent to leave the profession.[35] Farr-Wharton et al., found that poor nurse/supervisor relationships lead to increased nurse replacement costs.[36] Another supervisor competencies is supporting. Blomberg puts clinical supervision as an approach that can be used to support nurses for complying with the workplace.[37] Johnson writes that effective supervision includes the elements of counseling.[38]

According to the studies mentioned above and based on the present research findings, having sufficient competence in all aspects of scientific knowledge and clinical skills, management, communication, ethical and professional behavior, teaching and support, competence in the supervision process, is very important, but no compiled program has been planned or collected yet. So, it is necessary to plan a program for supervisor preparation. But unfortunately, program in this context has not been designed and developed. It is, therefore, necessary that a program be provided for the preparation of supervisors.

Supervisors participating in this study had requested for special training methods that enhance their competence. Mather et al. found the need to organize workshops, and appropriate education and training on professional development enables the clinical supervisors give positive performance.[39]

  Conclusion Top

It is necessary to enable supervisors to play a worthy role of clinical supervision at work. So, for the chief nursing officers and directors of nursing services, it is suggested that in order to achieve this objective, first supervised infrastructure should be provided, such as making the appointments and retention of supervisors, clarifying the duties and authority of supervisor, developing supervisory culture, specializing supervision, and conducting practice-based training; then the competent supervisors should be provided comprehensive and integrated training in aspect of acquiring scientific, managing, communicative, professional, ethical, pedagogical, and supporting adequacy. The chief nursing officers should provide training readiness and application practice-based teaching to supervisors for performing the supervisory role in an excellent way.

Clinical supervision is an effective way to improve the quality of health care. Clinical supervisor has an important role in guaranteeing quality nursing care and improvement of patient care, and helps in nurses' personal and professional growth. It is necessary to enabling supervisors to play a worthy role of clinical supervision at work. Therefore, for the chief nursing officers and directors of nursing services, it is suggested that in order to achieve this objective, first supervised infrastructure should be provided, such as making the appointments and retention of supervisors, clarifying the duties and authority supervisor, developing supervisory culture, specializing supervision, and conducting practice-based training; and then the competent supervisors should be provided comprehensive and integrated training in the aspect of gaining scientific, managing, communicative, professional, ethical, pedagogical, and supporting adequacy. The chief nursing officers should provide training readiness and application practice-based teaching to supervisors for performing the supervisory role in an excellent way.

  Acknowledgment Top

Researchers express their gratitude and appreciation for all participants in the study, such as matrons, supervisors, and head nurses. Project number 3124.

  References Top

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