3. AIMS OF THE STUDY
5.3. Effects of team supervision among the individual team members from the perspective of professional development
The effects of team supervision among team members were examined using follow-up inquiries and group interviews after the termination of the intervention. The following chapter focuses on addressing the first study aim from an individual team member’s perspective (see chapter 3).
During team supervision some changes were evidenced in the factors describing the individual factors of the prerequisites for professional development (Tables 12 – 14). Reflectivity (p= .010) improved on ward A (I inquiry mean of sum 43.3, SD 3.1 → V inquiry mean of sum 43.7, SD 3.2), but only occasionally and
slightly on ward D (I inquiry mean of sum 40.2, SD 2.7 → V inquiry mean of sum 40.4, SD 2.6). However, performance motivation (wards B, C and E, p=. 964 and wards A, D p=. 685) and growth motivation (wards B, C and E, p= .832 and wards A, D p= .092) remained unchanged during the intervention.
The low evidence of individual professional development was confirmed through the fact that the majority of the supervisees found that their expertise, theoretical approach, self-awareness and personal strengths remained the same during the intervention (Tables 9 a, b). A closer examination showed that especially the theoretical approach to practice had remained unchanged throughout the intervention (wards B, C and E: III inquiry 100%, n=24 and wards A and D: V inquiry 81.8%, n=18). However, an increasing number of respondents had reported deepened self-awareness (wards B, C and E: I inquiry 4.2 %, n=1 → III inquiry 29.2 %, n=7 and wards A, D: I inquiry 40.9 %, n=9 → V inquiry 45.5 %, n=10). Especially on wards A and D, which participated for three years, an increasing number of supervisees (I inquiry 68.4%, n=13 → V inquiry 84.2%, n=16) described the effects of CS on supervisees themselves, but also on their work patterns (I inquiry 52.6 %, n=10 → V inquiry 66.7%, n=12) (Table 10 b).
The described effects of team supervision on oneself focused on one’s relationship, self-examination, openness and degree of freedom (Table 15.) The supervisees’ attitude towards themselves became less critical meanwhile the positive view increased. During the course of the intervention the respondents’ attitudes had developed towards a ‘positive criticality’ and increased gentleness towards one-self (e.g. forgiving one’s mistakes and admitting weaknesses) with increasing fearlessness and courage.
Supervisees described increased self-examination and their behaviour and reactions with patients and colleagues. During the course of team supervision some respondents reported how they had learned to know themselves, their ‘blind spots’ and own goals, which directed their actions. Improved self-knowledge contributed to expressing one’s emotions and opinions. Increased openness and freedom were mentioned as effects of team supervision on oneself through consideration of things that had occupied one’s mind, but also listening to colleague. The above-mentioned effects served as a means of ‘emotional relief’ and increased effectiveness regardless of increased work pressures. Problems and negative effects were again mentioned.
Supervisees emphasised that team supervision had aroused very strong, negative and fluctuating feelings such as irritation, frustration and tensions that consumed energy. In extreme, but rare descriptions the feeling led to fears, depressed feelings or hardening. The discussed topics had also provoked awkwardness, displeasure, cynicism and withdrawal because of being ‘misunderstood’. Some supervisees were disappointed because of ‘dishonest’, superficial and fruitless examination of the topics.
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Tables 12.-14. Prerequisites for professional development: individual factors Growth motivation (OC1)
Inquiry I Inquiry II Inquiry III Inquiry IV Inquiry V Total
mean SD mean SD mean SD n mean SD mean SD n sum mean
---ward B 31.3 7.8 30.5 5.4 31.0 3.4 6 - - - - - 92.8 30.9
ward C 32.6 3.5 33.5 2.2 33.2 1.9 10 - - - - - 99.3 33.1
ward E 35.5 2.2 34.6 2.8 34.4 3.5 8 - - - - - 104.5 34.8
---( total ) 33.3 3.7 33.1 3.6 33.0 3.1 24 - - - - - 99.4 33.1
---ward A 33.2 4.1 34.3 3.1 33.2 2.8 13 33.7 2.8 34.1 2.7 13 168.5 33.7 ward D 32.7 2.7 33.8 2.1 34.1 2.7 9 32.0 4.9 33.9 3.2 9 166.5 33.3 ---( total ) 33.0 3.5 34.1 2.7 33.6 2.7 22 33.0 3.8 34.0 2.9 22 167.7 33.5 ---wards B, C and E ) statistical significance: between ---wards .069, factor .832, factor and ward .481 wards A and D) statistical significance: between wards .736, factor .092, factor and ward .272 Performance motivation (OC3)
Inquiry I Inquiry II Inquiry III Inquiry IV Inquiry V Total
mean SD mean SD mean SD n mean SD mean SD n sum. mean
---ward B 41.7 3.8 43.0 3.5 42.2 2.3 6 - - - - - 126.9 42.3
ward C 41.8 2.7 41.9 2.1 42.2 3.2 10 - - - - - 125.5 42.0
ward E 44.3 2.9 42.4 3.9 43.3 4.2 8 - - - - - 130.0 43.3
---( total ) 42.6 3.2 42.3 3.0 42.5 3.3 24 - - - - - 127.4 42.5
---ward A 43.0 3.7 42.1 2.8 42.9 3.4 13 42.8 3.5 43.3 3.3 13 214.1 42.8 ward D 42.4 3.5 42.9 4.5 43.1 4.3 9 43.3 3.4 41.7 4.2 9 213.4 42.7 ---( total ) 42.8 3.6 42.4 3.5 43.0 3.7 22 43.0 3.4 42.6 3.7 22 213.8 42.8 ---wards B, C and E) statistical significance: between ---wards .594, factor .964, factor and ward .285 wards A and D) statistical significance: between wards .939, factor .685, factor and ward .102 Reflectivity (RF1)
Inquiry I Inquiry II Inquiry III Inquiry IV Inquiry V Total
mean SD mean SD mean SD n mean SD mean SD n sum. mean
---ward B 42.7 1.5 42.2 1.7 41.7 2.2 6 - - - - - 126.6 42.2
ward C 41.4 2.2 41.1 3.5 41.6 3.1 10 - - - - - 124.1 41.4
ward E 43.1 2.7 41.9 2.8 43.3 2.9 8 - - - - - 128.3 42.8
---( total ) 42.3 2.3 41.6 2.8 42.2 2.8 24 - - - - - 126.1 42.0
---ward A 43.3 3.1 42.2 3.0 42.8 2.8 13 43.2 3.1 43.7 3.2 13 216.2 43.2 ward D 40.2 2.7 41.4 3.2 41.7 2.00 9 42.6 3.2 40.4 2.6 9 206 41.3 ---( total ) 42.1 3.3 41.9 3.0 42.3 2.5 22 43.0 3.1 42.4 3.3 22 211.7 42.3 ---wards B, C and E) statistical significance: between ---wards .448, factor .406, factor and ward .652 wards A and D) statistical significance: between wards .129, factor .143, factor and ward .010,
Table 15. Impact of team supervision on oneself and one’s work patterns
WORK PATTERN IMPACT ON ONESELF
INITIAL STAGE OF CS
PROCESSING OF WORK PATTERNS, BROADENED AND REINFORCED JOB PICTURE - increased reflection, verification and analysis of matters, contemplation and more composed working methods
- clarified and consolidated confidence in one’s working methods, broadening of perspective
- less ‘selection’ of duties and increased strength to tackle ’unpleasant’ duties
PATIENT-ORIENTATION - more precise treatment of patients - decrease in routine-like attitude
RECONCILING AND CHANGING WORK PATTERNS OF ONESELF AND OTHERS
- changing working methods to agreed upon direction - consideration for colleagues’ work patterns and trust in colleagues
- adopting colleagues’ ’good’ work patterns as one’s own
PROBLEMS AND NEGATIVE EFFECT - increased carefulness and frustration
SELF-KNOWLEDGE
- decreased criticalness and reinforced positive self-relationship
INTROSPECTION
- increased introspection and self-observation, contemplation on one’s feelings and reactions in relationships with patients and colleagues
SENSE OF OPENNESS AND FREEDOM
- relieved mind and increased openness towards expressing one’s feelings as a consequence of contemplating thought-provoking issues and of listening to others
PROBLEMS AND NEGATIVE EFFECT
- negative, confusing and seething feelings: irritation, frustration, tension
-irritation, discomfort and cynicism caused by topics - disappointment caused by superficial examination,
’dishonesty’ and fruitlessness
INTERMEDIATE STAGE OF CS
DEEPENED PROCESSING AND CHANGE IN WORK PATTERNS
- working method changed towards a contemplative and investigative direction examining wholes broadly from different perspectives with clarified causal relationships - development of flexibility, assertiveness and ability to tackle difficult issues, decrease in ’black-and-white’
attitudes
- increased observation and assessment of one’s work patterns
NEEDS BASED PATIENT CARE
- increased consideration for patients’ needs
CLARIFYING AND CHANGING WORK PATTERNS OF ONESELF AND OTHERS
- jointly altered work patterns
- improved consideration for colleagues’ different work patterns, understanding and acceptance
- opportunity to change one’s work patterns by adopting colleagues’ best methods
PROBLEMS AND NEGATIVE EFFECT - increased cynicism and reserve
- drop in work motivation because of negative personal criticism
POSITIVE, CRITICAL SELF-RELATIONSHIP - increased open and positive criticalness
- increased ’gentleness’ towards self, forgiving one’s mistakes and admitting weaknesses
INTROSPECTION AND SELF-KNOWLEDGE - improved knowledge of oneself, one’s ’blind spots’
and goals
- increased courage to express one’s feelings and opinions
SENSE OF FREEDOM
- sense of ’psychological’ relief and increased efficiency despite increased work pressure
PROBLEMS AND NEGATIVE EFFECT
tackling matters at personal level causing feelings of repression, exhaustion, fear and depression; criticism and ’verbal attacks’
- emotional fluctuations or hardening
END STAGE OF CS
CONFIRMATION AND CONSOLIDATION OF ONE’S WORK PATTERNS
- consolidation of one’s work patterns, increased self-confidence and self-esteem, increased sense of responsibility
- more structured and precise work
CRITICAL PATIENT-ORIENTED APPROACH AND MANAGEMENT OF DEMANDING PATIENTS RELATIONS
- easier to encounter difficult patients
- increased consideration for treatment of patients - challenging routines based on different perspectives RECONCILIATION OF WORK PATTERNS OF ONESELF AND OTHERS
- view of links between issues and actions - learning to ask for help from colleagues
- broadened view of how others think dispelled conflicts
DEVELOPED SELF-RELATIONSHIP
- increased fearlessness and courage to ’speak out’ and to express one’s opinions
SELF-KNOWLEDGE - increased self-knowledge
SENSE OF FREEDOM AND OPENNESS
- sense of freedom and relief because of talking about joint matters with others
PROBLEMS AND NEGATIVE EFFECT
- risk of being misunderstood while ’speaking out’ and decreased willingness to take a stand
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The effects of team supervision on work patterns focused on processing and changing the patterns, matching one’s own and colleagues’ work patterns, but also on a patient-centred and patient-originated work approach. Supervisees reported that the processing, monitoring and assessment of their own work patterns had increased during the intervention. Respondents had also noticed that their perspectives had broadened and acquired a more investigative emphasis, whereas ‘black-and white’ attitudes and selecting duties had decreased. During the course of team supervision, the supervisees’ confidence in their own work patterns strengthened and their pace of work slowed down. Towards the end of the intervention self-confidence and self-assurance with regard to one’s work patterns improved, the supervisees’ responsibility increased and led to a more accurate and organised work style. The patient centred approach with the previously increased emphasis on patients’ needs, but also critical questioning of prevailing routines were described as closely related to the effects of team supervision on the work patterns. Encounters with difficult patients were perceived to be easier and more attention was paid to patient care.
Supervisees reported that during team supervision they had started to pay more attention to their colleagues’ work patterns. During the intervention, the confidence in and understanding and approval of colleagues’ work patterns increased and the respondents reported that they had learned to ask for help. An important effect on work patterns was that supervisees had started to adopt the work patterns of those colleagues they found ‘effective and good’, and the work patterns thus transformed into a more consistent direction. The problems and negative effects mentioned were that reservations, wariness, frustration and cynicism had increased, and some team members had lost some of their work motivation if their work patterns had been commented upon.
The team perspective on the development of work
The interviewed teams examined the development and effects of team supervision from the perspectives of (a) what is work/nursing about, (b) by whom and how is the nursing care implemented. The following categories were found: (1) nursing care characterised by its common course, (2) sources of knowledge for work, (3) ‘oneself working within team’ and (4) team composed of individual ways to work. The categories are described more closely next.
Nursing care characterised by its common course
Nursing care was discussed vividly in all the five participating teams under the interview theme of ‘team supervision and work’. The conceptions in the teams differed but were describable on three hierarchically related levels. The interviewees’ perceptions showed variation in the conceptions of nursing, its nature and basis. On the highest category level, the interviewees’ conceptions conveyed that nursing is patient-oriented action, based on common agreements and mutual decision making. The interviewees’ perceptions indicated that the work, i.e. nursing care had developed during team supervision. The following example of group interviews describes this.
Example 13(ward A):
Interviewee S: … the things discussed in CS … you learned to see how the team work … in a ward situation.
And you learned how people think … when we discussed our difficult patient cases … (some comments excluded)
Interviewee H: … yes and on the other hand we’ve made joint decisions … about policy lines … we’ve discussed them before but … but to be able to make progress … once we’ve decided something … we must stick to it. And then it recurs on the ward and is deployed in our work… we’ve been more organised in terms of planning’
The conceptions that formed the second level described nursing through the continuous changes and development processes witnessed by the interviewees. The more specific focus on care (i.e. patients) and its basis remained, however, implicit. The interviewees’ perceptions of nursing and its common course indicated that the changes and developments, strongly emphasised in the teams, were brought about jointly.
The conceptions in this category conveyed doubts about the effects of the intervention. It was seen that the effects were mixed with ‘change’ and thus impossible to distinguish as effects. The following example is an extract from the group interview made on ward D.
Example 14(ward D):
Interviewee K: ‘… big changes are going on at different levels … the system is about to change completely:
the day surgery unit started to operate, one ward was closed down … posts were cut down… how could you even begin to specify all this?’…
The lowest category level was comprised of some interviewees’ perceptions with an emphasis on practice and procedure centred nature of nursing. The interviewees’ conceptions were not contradictory, and they seemed to have a shared view of the foundations of nursing actions. The perceptions were, however, focused without explicit discussions on the patient aspect, and on changes or developments in nursing. On this level of the category, the interviewees' conceptions indicated that the contribution of team supervision to nursing or to the joint actions was more or less non-existent. The next example describes this critical perspective on team supervision from ward B.
Example 15 (ward B):
Interviewee S: ‘Right… this work of ours (at the operating theatre) was so alien to them … the whole system
… it sort of ended there and then’.
Interviewee N: ’Our mentalities differed enormously … they (clinical supervisors) kept repeating the same thing …whereas we get right down to the point without beating about the bush’…
Sources of knowledge for work
The sources of knowledge at work were discussed in three of the five interviewed teams (A, B, C). The conceptions comprised three categories that were hierarchically interrelated. Variation showed in the interviewees’ perceptions of attaining knowledge for work in relation to colleagues and to the nature of knowledge. The highest level of conceptions indicated that the colleagues were a source of knowledge in work and that this was evolving and possible to share. The interviewees’ perceptions indicated that collective knowledge for work was created in team supervision. This is described in the following extract from the interviews.
78 Example 16 (ward A):
Interviewee A: … ‘we discussed our joint care policies … patient cases … they sort of enabled us to generalise these cases to corresponding situations in the future … and ask for help … and certain policy lines as to our work … and not sit waiting until a problem arises but … and when there is a problem we don’t try to patch up things but approach it from another direction, try to make things easier on ourselves, the nurses’
The conceptions forming the next level focused on discussions about common knowledge for work. The interviewees examined ‘the shared knowledge’ mainly because they saw that it was important to clarify it and to make it available for all team members on the ward through concrete means. The interviewees’
perceptions of the nature of knowledge or their colleagues’ contributing role for producing knowledge for work was not explicitly expressed during the interviews. In the following example this is shown in a discussion about a file that was created for common use.
Example 17(ward C):
Interviewee K: ‘We discussed it… we all had a slightly differing approach to work … it makes it explicit … that we do differ from one another in our approaches …
Interviewee M: ‘We’ve grown more sensitive as to other people’s approaches’ … (some comments excluded)
Interviewee T: ‘…isn’t that … the file that we are compiling for joint use? … that we would all have the same knowledge base’ …
The conceptions that the knowledge for work was received during different training courses and study days formed the lowest level of the category. Interviewees perceived that a great deal of knowledge was available, and that course participants served as sources of knowledge thus making it accessible to all (i.e. in the team).
The following extract from a group interview describes this.
Example 18(ward B):
Interviewee N: ‘We have lots of training opportunities … people share the things they’ve learned with the rest of the people …’
‘I as a team member’
The conceptions concerning ‘I as a team member’ comprised four hierarchically inter-related categories.
These categories emerged in the four interviews on the wards (A, B, D, E). Variation was discovered in the interviewees’ perceptions of ‘oneself’ in relation to patients, colleagues and team through work. The highest category was formed of wide-ranging and flexible conceptions of ‘oneself’ in relation to work including the different parties. Flexibility indicated support for colleagues in the team and at work. The interviewees perceived that team supervision had contributed to realising this but had also helped to manage and prevent their own feelings of guilt. The effects of team supervision were thus seen in terms of improved self-awareness. This is described in the following extract from one group interview.
Example 19 (ward A):
Interviewee S: …’We talked about collegiality … that we should act as a united front and be collegial. And sort of provide support for the other person in a difficult situation …And not to blame people for not acting in the ‘right’ way … but to support them and not condemn them’ …
(some comments excluded)
Interviewee N: ‘Well it was good to see that we all share the feeling of guilt … that in itself was a big step forward…’
Interviewee E: ‘Exactly… some people just admit to it more readily than others … and admit to their mistakes …’
The conceptions that focused on ‘oneself’ in relation to work formed a narrower level. In this category the conceptions were not wide-ranging, but described in depth one’s own relation to work. Interviewees perceived that one’s own genuine and individual relation to work had been clarified through distinguishing this from teamwork and the relations with colleagues. In other words, the conceptions in this category were reversed compared to the above-mentioned highest category level. However, the patient aspect was also included in this category, but in the interviewees’ perceptions it was connected to ‘one’s credibility’ in patient relations and thus as part of work. The conceptions in this category suggested a positive contribution of team supervision. The following example describes this level of conceptions in one group interview.
Example 20 (ward E):
Interviewee P: ‘Right… to have the courage to act as a genuine human being … there and then … I feel that our attitude towards doctors has changed a bit … although we spend eight hours a day face to face…as far as these outbursts are concerned … we started to think about the nature of our relations and we were startled at our feelings about other people’ …
(some comments excluded)
Interviewee S…’It really made me think about what patients might think when we keep on talking and work at the same time … do they think that we are capable of that … or is it empty words, just things that we say without meaning it’
The conceptions that formed the next level concentrated on specific aspects of work. Interviewees presented different viewpoints, but the subject (i.e. oneself) of work was not clearly expressed. In contrast, the discussion was tinged with unachieved goals at work. The interviewees’ own conceptions of their relation to work remained blurred. However, the perceptions in this category were tinged with a positive emphasis on the support provided by team supervision for the teams. It seemed that the support had also contributed to and extended the team members’ self-awareness through insights and expressions elicited during team supervision. An extract of the group interview on ward D is shown in the following example.
Example 21(ward D):
Interviewee A: … ‘during the three years of CS were went through enormous changes. We introduced the primary nursing model … it was too much to handle … and our scope of operations exploded … we felt that we are inadequate … It was sort of having to give up something … and concentrate on this one issue only..
Now I feel that we should start we should take it slowly in CS … (some comments excluded)
Interviewee V: ‘it (team supervision) did have its value in the sense that we were able to realise how much we’ve accomplished … and endured change … and become healthier … so we must have achieved something’ …
The conceptions that touched the requirements for one’s work in passing formed the lowest level of the category. Although the interviewees described their conceptions only in a few words, it was obvious that the perceptions in the team were not contradictory. In this category the perceptions were, however, tinged with