Critical Reflection and Thinking on Clinical Supervision and Learning

Introduction

For the purpose of this essay the terms clinical supervisor and mentor will be used interchangeably as they are seen as essentially the same in this context.

Classrooms and textbooks teach one to care for a patient whom many a time s/he will never really encounter as seldom is such a classic patient seen in reality. One ought to acknowledge that one needs to know the theory to be able to apply the practice when on the clinical area. The academic side of ones learning should not be underestimated by placing all the importance in the practical experiences one encounters. Nevertheless the intricacy of generating and putting ones knowledge into real life situations may only be understood through experiential practice.

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As Eraut (2009) stated learning in university does not provide the same learning contexts as the working environment. Nursing has historically acquired knowledge through various venues such as traditions, trial and error, research, intuition, role modelling and mentorship, reasoning and experience. Therefore experiential learning could well play an important part of the basis of genuine education if utilised and developed well. However as will be discussed in this assignment experiential learning alone at times is insufficient as a basis for education in the complexities of learning in practice, clinical supervisory roles and being a competent health professional.

1. learning in practice

Eraut (2007) longitudinal study concluded that under the appropriate settings new recruits learned more on the job than through formal methods. There is a need for apt learning opportunities and a supportive environment to encourage and learning in the supervisee.

The Experiential learning cycle described by Kolb (1984) integrates four elements: doing, reflecting, learning and applying that learning. The cycle then integrates four ways of knowing – tacit knowledge which can be seen as the underpinning of ‘doing’ in ones work. One knows ‘automatically’ and continues to practice intuitively. Next is reflective knowledge which Mezirow (2000) describes as involving openly reflecting and critically reflecting on one’s own practice. The last two are ‘knowing that’ (propositional learning) which materializes from critical reflection and ‘knowing how’ is the final segment of the Kolbs cycle where one finds competence. One may wonder whether the clinical workplace always enhances favourable conditions for experiential learning to present genuine education.

1.1 The Clinical workplace

Glen (2009: pg 498) referring to the apprenticeship model that had been around since Florence Nightingale states that although the model entails structured supervision together with periods for reflection the outcome was more aimed at accomplishing the work tasks that on genuine reflection. The benefit of this model is that it provided newly qualified nurses that had achieved ample experience and seen as a skilful and experienced novice – therefore one could see the basis of education from experiential learning in this model. However this model is no longer in use and may have been abandoned too early (Mc Cormack, Kitson, Harvey, Rycroft-Malone, Titchen and Seers 2001).

Nowadays nurse education is run differently but one can still remember the concern in the ‘hospital trained’ nurses when training for nurses went into university level. One of the main issues of concern was that nursing is a practice profession so why the need for extra knowledge to become a competent practitioner? Should nurses not be taught more in clinical practice and less in the classroom? “Knowing and doing are not the same thing” was voiced out many a time. This adds to the belief of many that learning in practice is the basis of education.

The culture of the clinical practice will also have a vital influence on one’s experiential learning outcome. ‘The way things are done here’ (which could be in a positive or negative attitude) at either the clinical practitioners (individual) level or at the organisation level or both levels can effect ones successful end result (McCormack et al 2001).

On the other hand numerous other factors such as, the organisation one works in, nurse shortages, working in high patient acuity, inadequate clinical facilities, patient’s having shorter lengths of stay, unwillingness by the nursing staff to provide clinical supervision and the a scarcity of nurses in the clinical area add to the challenge of obtaining genuine education through experience.

Supervisees need to be ‘armed’ with the necessary skills to analyse problems from varying perspectives. Experiential learning may present the basis of education if the right challenge is provided; that is within the level of the supervisees’ knowledge and therefore presenting a beneficial outcome. If not the experience may end up being overwhelming and rather than learning through reflecting on a situation it could result instead in utilising eventually ineffective coping methods.

One has to exploit an experience through reflection in order to sort out, comprehend, give meaning and hence make appropriate and proactive use of it. Experiential learning thus needs to provide the possibility of developing reflective and other conveyable learning skills in order to promote the education supervisees need and to learn from the experience.

1.2 Critical reflection and thinking

Hunt and Wainwright (1994, p.84) point out that: “Regardless of the time spent in a particular area of practice, practices that are devoid of rationale for actions are purely task or procedure orientated and lack critical inquiry”.

Several authors have emphasized on the fact that reflection is requisite in bridging the theory and practice gap (Kolb, 1984, McCaugherty, 1992, Schön, 1987). Implementing theory into practice necessitates practitioners to critically reflect not only on ones own practice but also on the implications of ones interventions. The literature has moreover highlighted reflection as imperative when endeavouring to incorporate theory with practice (Meretoja, Eriksson & Leino-Kilpi, 2002).

Lisko and O’Dell (2010) acknowledged that nowadays working in such a complex clinical environment necessitates one to employ top notch critical thinking, they also add that to offer such experiences for one to learn from and to reflect on has become essential – this can be achieved in the many different experiential learning opportunities one encounters. Therefore one notes that the nursing profession is inclining to acknowledge and encourage reflective practice and critical thinking and that it also offers education from experience for both supervisors and their supervisees.

Baltimore (2004) highlights that since optimal patient outcomes will depend on nurses actions, nurses need to wholly comprehend a situation in order to critically think. Benner (1984) stresses that recording of practical experiences and reflecting on them is essential in the development and extension of theoretical knowledge. While Kolb’s double knowledge theory (Kolb, 1984) depicts that one knows things by being able to do them in conjunction with thinking ‘reflecting’ about them. One can perceive that it is accepted by the literature that reflection provides the opportunity to go over decisions taken and assess as well as evaluate ones learning in order to improve not only ones own practice but also whoever they supervise.

Then again does one working climate with its time constraints enhance all this? Is it possible to perform reflective practice whenever needed (Westberg & Jason, 2001)? Is reflection not a complex skill that’s basis ought to be taught in the classroom too in order to be fulfilled in practice? Therefore can experiential learning alone provide the ability of how to reflect and even more critically reflect on ones experiences and ultimately gain knowledge from them?

In cooperation with reflection comes along the need for feedback and coaching which are seen as important aspects in experiential learning while supervising; not only for the supervisee but also for the supervisor.

2. Clinical supervision

Price (2004) highlights the reasons to why the role of a mentor has come into being, illuminating that the learners’ (supervisees) necessity to mature into a competent and confident qualified nurse and performing practice astuteness, good clinical skills, attitudes and clinical techniques are best acquired in the clinical practice environment.

Being assigned to a clinical supervisor may provide the supervisee with opportunities that may not or cannot be portrayed in classrooms or textbooks. One may wonder about whether clinical supervisors have enough morale and positive attitudes left in them to want to carry on providing supervision in such hectic working environments and nurse shortages. Eraut et al’s (2007) study findings noted that designated mentors in nursing were either excellent in providing a sustenance or practically useless. Therefore is Dewey’s statement right in the latter situations? Will experiential learning provide competent practitioners in these situations?

To become a ‘good’ mentor/supervisor one reads tall lists about the characteristics required. Rowley (1999) offers a list of ‘virtues’ a good mentor should hold including commitment towards mentoring and its values, acceptance of one mentees regardless of ones personal beliefs/likes/dislikes, effective teaching qualities, good communication skills with the capability to adapt to ones supervisees learning nature, and set the example of need to be a constant learner and being optimistic towards ones mentees/supervisees. Then Quinn (2007) describes the humanistic qualities necessary, such as understanding, being approachable, supportive and inclusive in addition to being positive towards learners and an excellent management approach to education values. Gray and Smith (2000) add a sense of humour to their list.

Therefore one could conclude that the supervisor must consistently show high standards of personal conduct and an apt approach towards ones supervisees; with the belief that the supervisee will therefore take in and try to be like what they have seen as acceptable behaviour in the working place.

However Gray and Smith (2000) study findings portray another long list of attitudes supervisors may display to their supervisees – this time in the negative, to mention a few: delegating futile jobs, being of an unfriendly nature or worse still being unapproachable, showing lack of interest in their own job in addition towards the supervisee and even unpopular with the team they work within. Such supervisors certainly diminish the opportunity of transmitting education through experiential learning to any supervisee.

Burnard (1998) had rightly pointed out that being under the wing of a qualified nurse does not necessarily equal to learning. Learning in practice may mean to some as just ‘getting the job done’ and the issue of focusing on the learning needs of the student or new recruit are left in the shadow (Andrews & Wallis, 1999) and therefore excluding the importance of applying and integrating ones knowledge (theory) to the clinical practice. Even worse, this hinders Dewey’s belief of experience being the basis of all education.

Having the ability to organize the delivery of care in sync with ones teaching and assessing responsibilities, maybe a prerequisite for a supervisor/mentor however as one notices from the literature is no easy task. On the other hand one must keep in mind that just as the newcomers may feel unsafe to practice because they lack knowledge so do some of the senior staff; some people are not capable (or find it extremely difficult) of learning, changing or moving on (Eraut, 2002).

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Clinical supervisors as all humans differ in how they present their significant attributes and may need to develop and improve their qualities. This will also provide the assistance needed in favour of experiential learning as a basis to education. Identifying and working on these key qualities should assist one in enriching ones supervisees learning environment. Then again the supervisee may also pick up the mal-practices of the supervisor, leaving one with the dilemma of who should be providing clinical supervision? Who can provide Dewey’s belief in of education through experience?

3. Expertise and Evidence Based Practice

Nurses’ clinical expertise is presumed to be an important factor related to quality of care in the clinical practice. Expert practitioners are seen as fundamental in the process of the training and the professional development of supervisees in addition to the efficient everyday functioning of a clinical area. Therefore it is necessary to articulate what are the particular prerequisites of one’s area of practice in order to provide beneficial experiential learning opportunities to ones supervisees. Through expert practice the experts share experience, knowledge and skills in the course of teaching and mentoring not only students and colleagues but also patients and their families; which are or should be an everyday practice to clinical supervisors, and therefore contributing to offering an expert practice and better service to meet the patients’ needs.

Excellence in health care is vital, as excellence applies to continuing learning and research that will augment and further develop nurses in their profession and give a boost to the nursing practices (Castell, 2008). Nowadays lifelong learning and research in nursing practices are acknowledged as prerequisites in order to maintain and move forward nursing competence (Avis & Freshwater, 2006; Westberg & Jason, 2000). Therefore even if experiential learning is an important basis of learning in practice and is the how, what, why and when all gathered together there still remains the prerequisite of up to date evidence based knowledge/practice.

Avis and Freshwater (2006) state that Evidenced based practice EBP is perceived as a significant concept in competent professional nursing practice and is measured by one’s ability to integrate EBP in the care on is to provide. EBP is acknowledged as an indispensable factor of nursing competence. But is EBP giving too much importance to scientific evidence and thus underrating the role of individual nursing expertise and its clinical judgement (Hardy, Garbett, Titchen & Manley 2002)?

Supervisees need clinical supervisors with the apt level knowledge, skills and training not only in their practice but also in their teaching/learning approach and environment in order to enhance and smooth the supervisees’ individual progress and education.

4. The learning environment – ‘learner centeredness’

Another aspect literature has shown is that clinical supervisors should move on to the importance of providing a learner approach rather than the more customarily utilised teaching approach. Through a learner centred approach one will in addition need to inspire a sense of curiosity that will drive the supervisee to absorb everything s/he can see or hear or read about nursing in order to improve the efficiency and effectiveness of his/her eventual competent practice. This will necessitate the supervisor to have the supervisees’ needs at the hub of the activities being performed – not an easy task within clinical areas and their always increasing workloads and the time factors of a clinical environment (Waldock 2010).

Learners obtain knowledge from experience which they then incorporate into their own system of concepts; and thus the reason why one should emphasise on the importance of the supervisee’s active share in learning. Supervisees in order to learn from their experiences have the responsibility to discover their own clinical educational needs through their personal agency and find ways how they may retrieve these clinical needs; which may be through their supervisors or others in the clinical area that may provide assistance (Eraut 2008).

One must provide a meaningful experience for the supervisee which ends product will be what the supervisee will perceive to be relevant to their learning needs (Wlodowski 1999). Learning centeredness is seen as being beneficial to the supervisee as it will also provide opportunities that may not be encountered during formal teaching environments (McKimm and Jolie 2003). Therefore emphasizing on the notion that experiential can offer the basis to education especially if one notes that basically everything that happens in the clinical area; be it at a client’s bedside, in a clinic, ward or operating theatre and the likes, can provide a learning opportunity.

The supervisor must however focus on the supervisees’ learning needs and by working together, given that this is a two-way interaction, s/he will gain the knowledge and abilities required and therefore enhance his/her knowledge. As a consequence this may provide experience as a basis to education.

Providing a learning centeredness environment can provide the opportunity for the supervisee to work in conjunction with their supervisor and at the same time presenting the opportunity for the supervisee to not only be involved in the activities but also to learn new skills, techniques, perceptions, to acknowledge the variety of knowledge and expertise others behold and to even witness tacit knowledge.

4.1 Tacit knowledge

Observing provides the opportunity to understand quicker and therefore requiring briefer explaining. Another benefit of this attitude of learning through observation and discussion is that it can demonstrate the tacit knowledge a supervisor holds on everyday and intuitive and instinctive decisions that are difficult to explain (Eraut 2009).

Epstein & Hundert (2002) recognise tactical knowledge as intuition and pattern recognition they continue to add that intuition plays a part in acquiring competent practice. Epstein et al’s study in addition revealed that doctors now believe that their competence is reliant also on tactical knowledge – a fact that nurses have valued for a long time and believe that competence is not only based on explicit knowledge but also tactical knowledge. Certain skills cannot be disseminated by formal teaching alone. Skills are as a result defined in terms of knowing how to do things, an example being Polanyi’s (1958) Balance Principle which could apply to nursing skills where the novice will watch and then practice. Hence the importance of learning methods

4.2 Learning methods

Providing the right learning method is so complex. From the literature one notices that there is no perfect recipe to learning theories. A clinical supervisor teaching supervisees in the clinical setting has a major impact on those supervisees’ outcome performance. The supervisor’s methods may have the influence to enhance and facilitate the supervisees learning and accommodate new learning in clinical practice or else to curb the supervisees’ ability to apply knowledge and skills.

Frankel (2009) points out that the premise to clinical learning methods may be ineffective if they are not tailored to the supervisees learning style and continues to highlight that learning methods vary to the individual and thus the importance in providing the most fitting for that individual to learn appropriately. Everyone has some particular favoured method of collaborating with and processing knowledge. This is one of the reasons why one may agree to Eraut (2002) argument that one should not concentrate on which learning theory is right or wrong but on the contrary one should give importance on how to obtain maximum benefit during the learning process. One could add the maximum benefit in order to provide from competent practitioners.

The supervisees may be at different levels in their course or novices to certain areas of their workplace and thus learning from experience should not be presented or provided as a ‘one size fits all’ situation (Quinn 2007). When providing experiential learning as a basis to clinical learning the clinical supervisor has to take into consideration the supervisees previously gained skills and knowledge and also the expectations they may have brought along.

As it has been observed there is no strict recipe to stick to in order to produce a ‘right’ teaching/learning strategy. Together with theoretical education and once one has found a suitable environment, the ‘right’ strategy for both the supervisee and one that the competent supervisor is apt at carrying out, what is left is both the supervisees and supervisors self motivation to learning, their sense of curiosity and inquisitive minds, willingness to not only knowing more but also to change (Khomeiran, Yekta, Kiger, & Ahmadi 2006).

5. Competence

It is indispensable that clinical supervisors employ well-established clinical skills and a high standard of competent nursing practice that will sustain effective facilitation of student learning (Gaberson & Oerman, 2007).

Rutkowski (2007, p.37) describes assessing competency as complicated and being based on direct observations as well as entailing ones opinion of values, which are subjective and hold personal beliefs which may vary from one to another. For experience to be the basis of education one must understand what competency really is and what it signifies. When one thinks of all the controversies on competence one may find it complex to agree that experience alone can provide competent practitioners.

Conclusion

Although experiential learning may definitely have its importance in providing a basis for education one comes to the conclusion that so do theoretical learning and personal traits of both the supervisor and supervisee. These are indispensable factors to learning in addition to motivation, curiosity, an inquisitive mind and the drive to keep on learning. To know and not to act is not to know. Experiential learning is both transformational and transmissional; it provides changes in ones attitude and behaviour and should not be seen as only as the shift of ideas or knowledge.

The practical and academic sides of the supervisor and supervisee are both important. The academic side provides knowledge, broadens ones horizons and tests ones manner of thinking. Experiential and academic learning compliment each other thus the skills gained from both learning styles should bring into being a safe, competent and knowledgeable practitioner and all this may assist Dewey’s belief of experiential learning being the basis of education.