Taking care of the carers

Caring for patients at the end of life is emotionally demanding work but regular clinical supervision for nurses can help to buffer against stress, writes Andrea Gregory.

At the end of 2010, the Northern Adelaide Palliative Care Service implemented an innovative and integrated model of care to meet the mental health needs of patients. To do this, the Specialist Mental Health Initiative in Palliative Care, funded through the Department of Health and Ageing Local Palliative Grants Program, sought to develop both knowledge and skills within the interdisciplinary community team as well as facilitating direct mental health support to the patient and their families.

During the early months of the project, a needs assessment was undertaken with the nursing staff to gauge their training needs and professional development. This identified a particular area of need for nurses working in palliative care: the lack of formal structure for critical reflective practice and debriefing.

The palliative care nurse is faced with unique causes of stress: a high turnover of patients, an intense level of involvement in emotive settings, the frequent “saying good bye” and then “saying hello” to the next referral; all of which have a cumulative emotional impact. The push towards developing a supervision framework emerged as nurses began to speak together about their needs as professionals and the recognition that the nature of their work has a personal impact.

The value of clinical supervision to nurses and the health service is supported in the literature. In Meg Bond and Steve Holland’s 2010 book, Skills of Clinical Supervision for Nurses, focused support is recognised as the “vehicle for developing and sustaining clinical practice”; with clinical supervision the “route to developing and maintaining healthier individuals in an emotionally healthier workforce culture”.

It is well evidenced that effective supervision plays a part in ameliorating the emotional, physical and spiritual impact of working in high stress environments such as palliative care, and is thus a registration requirement for psychologists and social workers. The extent to which this practice has become an expectation for South Australian nurses and the broader nursing workforce is more sporadic.

To work, the implementation of clinical supervision requires commitment both at a personal and organisational level. The practitioner is engaged in an active process of reflection and supportive feedback, using the lens of clinical supervision to magnify specific features of practice or to expand the myopic vision of what’s right in front of you to a wider context.

For example, discussion about an individual patient who is demanding of staff time may lead to reflection on the nurses’ own emotional responses, assumptions and patterns of behavior. This facilitates professional and personal development, and the organisation, in return for its contribution of time and resources, it develops a more accountable, effective and stable workforce.

Prior to this project, multi-disciplinary handover meetings had been the main forum for discussing practice. These meetings are process-driven and task-focused, and thus are not conducive to clinical reflection, which is the core of effective supervision. Nurses articulated their growing frustration at not being able to get perspective on issues, consequently what I call “car-park debriefing” was taking place, that is, discussing issues in a haphazard forum which could only sustain subjectivity rather than foster objectivity and resolution.

Rather than being viewed as negative, this emerging awareness allowed energetic discussion about how things could be done differently. A number of the nurses had previously practiced within a clinical supervision framework and they played an important role as enablers and change agents throughout the process.

Although the potential value for clinical supervision is promoted, the literature also draws attention to potential obstacles, such as time pressure, the transition of an idea into a working model, and individual resistance. Bond and Holland suggest four levels of individual resistance as represented in the below table. This provided a conceptual framework to encourage an awareness of the potentially different positions that were held by members of the team.

As the psychologist attached to this project, I was asked to facilitate the development of the supervision framework because of my skills in this area and as a professional who was positioned outside of the team involved.

An already established nurses’ meeting time was used to set the direction and identify key issues.

The emphasis was placed on the value of the process regardless of the outcome. The exercise in and of itself was viewed as a personal-professional development and a team-building opportunity. A mixture of discussion and education approaches was chosen to take account of differing learning styles and to meet the desired outcome from the meeting, for example, the development of shared ownership of the framework or skill development. This was a process of exploration not imposition.

One challenge is to maintain momentum through the vicissitudes of everyday clinical life. Staff changes and leave have impacted on the timing of education sessions and raised the dilemma of balancing inclusivity of staff joining the process along the way with avoiding endless reiteration and risking excessive delay in implementation. To combat this challenge, we have continued to work towards a tangible supervision framework as a key goal.

A further consideration is the choice and sourcing of supervisors. A number of options are being considered including peer supervision and accessing external supervisors on a mutually beneficial basis.

In any new development, evaluation is an essential part of the process. Outcomes that can be assessed include clinical performance, staff emotional wellbeing, quality of patient care, team morale, and changes in staff’s perception of their professional identity. Regardless of future outcomes, the process of developing a clinical supervision framework has brought with it an invigoration of staff cohesiveness and professional optimism which have already made this process worthwhile.

Andrea Gregory is a clinical psychologist with the Specialist Mental health initiative in Palliative Care project at the Northern Area Palliative Care Service, Adelaide

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