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Journal of Nursing Management, 2012, 20, 152–158

Reflect and learn together – when two supervisors interact in the learning support process of nurse education MIA BERGLUND

RN, PhD

1

¨ GREN , REET SJO

RN, DDS, PhD

2

and MARGARETHA EKEBERGH

RN, PhD

3

1

Senior Lecturer, School of Life Sciences, University of Sko¨vde, Sko¨vde, 2Senior Lecturer, School of Health, Care and Social Welfare, Ma¨lardalen University, Va¨stera˚s/Eskilstuna and 3Professor, Department of Health and Caring Sciences, Linne´universitetet, Va¨xjo¨, Sweden

Correspondence Mia Berglund School of Life Sciences University of Sko¨vde Box 408 541 28 Sko¨vde Sweden E-mail: [email protected]

B E R G L U N D M . , S J O¨ G R E N R . & E K E B E R G H M . (2012) Journal of Nursing Management 20, 152–158 Reflect and learn together – when two supervisors interact in the learning support process of nurse education

Aim To describe the importance of supervisors working together in supporting the learning process of nurse students through reflective caring science supervision. Background A supervision model has been developed in order to meet the need for interweaving theory and practice. The model is characterized by learning reflection in caring science. A unique aspect of the present project was that the student groups were led by a teacher and a nurse. Method Data were collected through interviews with the supervisors. The analysis was performed with a phenomenological approach. Results The results showed that theory and practice can be made more tangible and interwoven by using two supervisors in a dual supervision. The essential structure is built on the constituents ÔReflection as Learning SupportÕ, ÔInterweaving Caring Science with the PatientÕs NarrativeÕ, ÔThe Student as a Learning SubjectÕ and ÔThe Learning Environment of SupervisionÕ. Conclusion The study concludes that supervision in pairs provides unique possibilities for interweaving and developing theory and practice. Implications for nursing management The supervision model offers unique opportunities for cooperation, for the development of theory and practice and for the development of the professional roll of nurses and teachers. Keywords: caring science, nurse education, supervision, supervisor Accepted for publication: 23 November 2011

Background The learning process for nurse students is characterized by an encounter between the studentÕs life-world, which means the subjective world of understanding and experiences, scientific knowledge and best practice. The aim for the students is to gain sufficient knowledge so that they can understand both the patient and the caring 152

context. Learning strategies are needed (Ekebergh, 2001, 2007) in order to provide such support and create the conditions necessary for a reflective process that strengthens the integration between the studentÕs lifeworld and theoretical and practical knowledge. There is extensive research on linking theory with practice in a learning process. Despite including different foci, one common theme is the highlighting of DOI: 10.1111/j.1365-2834.2011.01368.x ª 2012 Blackwell Publishing Ltd

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reflection as a support for learning, which can, for example, be found in Williams (2000), Welch et al. (2001), Melby (2001), OÕCallaghan (2005), Avis and Freshwater (2006), Crowe and OÕMalley (2006), Tveiten and Severinsson (2006) and Binding et al. (2010). A review of earlier research shows that the complexity in this area calls for more research in order to find the ÔcoreÕ of learning in professional training, such as the nurse education. One obvious shortcoming in previous research (Ekebergh 2007) is that little attention has been paid to the studentÕs lifeworld in the learning process. Another shortcoming concerns the importance of understanding the substance of learning and its scientific basis for developing adequate learning support. In the present project, both the theoretical and the practical perspectives are provided in learning support through a supervision model that includes two supervisors, one from each perspective. We have not found any studies that describe how two supervisors (for example a nurse and a teacher) work together in such a model. An educational project was thus performed with the aim of developing a supervision model that would support the interweaving of the studentÕs lifeworld with theory and practice in a learning process. The supervision model is based on a lifeworld approach and is called Reflection and Didactics, (REDI; didactics is used here as a synonym for learning support) (Ekebergh 2007).

Theoretical foundation The lifeworld approach emphasizes the learnerÕs learning attitude, experiences and embodied understanding. The platform for learning and reflection is thus oneÕs lifeworld. According to HusserlÕs (1973) philosophy, the latter is related to the natural attitude, which involves a type of approach toward everyday activities (Dahlberg et al. 2008). Consequently, a personÕs natural attitude is basically unreflective, but the lifeworld can be examined and conceptualized through reflection (Husserl 1973, 1998). Phenomena can thus be made aware of and can be made available for analysis instead of merely being taken for granted. Through reflection, we work with existing meanings, value sets and approaches. We discover and reconsider new versions of our experiences and attitudes. The reflective experiences are structured through consciousness, but how they are structured depends on earlier experiences. Consequently, the lifeworld is the platform for learning and through reflection the continuous learning process starts. Learning must always be understood in relation to the individual and his or her experiences, which are related to his or her learning. ª 2012 Blackwell Publishing Ltd Journal of Nursing Management, 2012, 20, 152–158

The supervision model The overall aim of the REDI project was to develop knowledge about the phenomenon, ÔTo support learning through reflective caring science supervisionÕ in the educational. Reflection and Didactics is characterized by learning reflection in caring science (caring science is the major subject of this nurse education and is focused on the patient) (Ekebergh 2007). The REDI supervision was carried out in groups of 8–12 basic and advanced level nurse students. The groups were led both by a teacher and a nurse. PatientsÕ narratives constituted the basis for the groupsÕ reflective work, and the students thus brought with them written narratives from dialogues with patients to the reflection group. The groups met every 2 weeks. The REDI model was carried out for 2 years and the didactic challenge entailed the creation of a learning environment that recognized both the patientÕs and the studentÕs lifeworlds (Ekebergh 2007). All the teachers and the nurses in the project received training in a 5-week course, Lifeworld Didactics, the major contents of which were how supervision based on lifeworld theory can support reflection and learning. Furthermore, it was created around the core elements of caring science supervision and its usage. The course started with a theoretical module that was followed by practical training, where the participants were able to practice different methods of caring science supervision and become familiar with working in pairs in the supervision sessions. A total of 22 nurses and 18 teachers participated.

Aim The specific aim for the present study was to describe the significance of supervisors working together in supporting the learning process of nurse students through reflective caring science supervision.

Method The phenomenon, Ôthe meaning of supervisors working together in supporting the learning processÕ has been studied with reflective lifeworld research (RLR), which is based on phenomenological epistemology as described by Dahlberg et al. (2008). In the RLR approach, openness is used as a guiding tool for the methodological work. This entails the researchersÕ understanding, and in particular their pre-understanding, being ÔbridledÕ in relation to the phenomenon studied. Such openness involves the researchers not allowing theories or other preconceptions to affect their understanding. 153

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Bridling thus means striving towards a scientific and reflective attitude, which entails being sensitive to the phenomenon and its meanings, with the particular aim of not making indefinite meanings definite too quickly.

Data collection and participants Data was collected in RLR interviews (Dahlberg et al. 2008) with the supervisors, either individually or in groups. The aim was thus to meet the supervisors with a bridled attitude towards their lifeworld and to obtain their experiences of the supervision model. The interviews were therefore focused on the importance of their experiences as supervisors working together in supporting the learning process of nurse students through reflective caring science supervision. The questions concerned how they integrated theory with practice and how they met the studentsÕ lifeworld and supported the understanding of the patientÕs world. The interviews with the teachers and nurses (i.e. the supervisors) consisted of eight group interviews with five people in each group. Four group interviews with nurses and four group interviews with teachers. Furthermore four individual interviews were carried out (two nurses and two teachers who had also participated in the group interviews). The informants for these individual interviews were strategically chosen from the groups in relation to whether or not they seemed to be able to verbalize and contribute with supplementary descriptions of experiences that had not been fully grasped from the group interviews. All interviews were tape-recorded and transcribed verbatim.

Data analyses The interview analyses followed the guidelines of the RLR approach (Dahlberg et al. 2008), which is based on GiorgiÕs (1997) phenomenological approach. The analysis process was directed toward discovering patterns and nuances of qualitative meanings that emerged from the narratives and transcriptions. The analysis was characterized by an intensive dialogue with the text seeking an understanding of the phenomenon. The challenge was to be sensitive both to the parts and to the whole, as well as the meanings of the phenomenon (Dahlberg et al. 2008). The authors attempted to find a meaningful pattern through the differences and similarities of meaning, and by allowing meanings to constitute ÔfigureÕ and ÔbackgroundÕ. The analysis process entails moving beyond given conditions and avoiding linear or causal explanations, which allows various meanings of a phenomenon to 154

emerge. Finally, it is possible to describe the general structure of the phenomenon. Its essential meaning is illustrated by the five constituents listed in the Results section below and the meaning of each is exemplified by statements from the interviews. The essential meaning can be understood as the aspect of its structure that binds the constituents together, and this is the background against which the constituents stand out as ÔfiguresÕ presented in the results (Dahlberg et al. 2008).

Ethical considerations This study, which was performed in 2006, conformed to the principles outlined in the Declaration of Helsinki (World Medical Association 2005) and the Swedish National Board of Health and Welfare (2003), and to the condition stipulated by the University management that the informants were given the opportunity, both orally and in writing, to consent to participate in the study.

Results The essential structure of the phenomenon is that REDI facilitates the interweaving of theory and practice. The effect of this interweaving becomes apparent through the two supervisors, whereas the interweaving moment is possible once the patientÕs narratives are analysed with both theoretical and practical perspectives. Mutuality and respect for each otherÕs knowledge is a characteristic of supervision but this unity is vulnerable and requires proximity and openness for each otherÕs lifeworlds in order for this interplay to become secure. The supervisors can become role models for the students, which can further develop through reflection. Both the supervisors and the students reflected during the supervision sessions and the latter found comfort in the fact that their feelings were recognized and articulated. The challenge for the supervisors was to meet the students in their individual learning processes while involving everyone in the group. This required a genuine interest that included an emotional commitment to the students and their learning. The goal was to have an open and flexible attitude with balance as a maxim: a balance between being flexible and challenging, and between being demanding and permitting. The essential structure is built on the constituents: Dual Supervision, Reflection as Learning Support, Interweaving Caring Science with the PatientÕs Narrative, The Student as a Learning Subject and The Learning Environment of Supervision. ª 2012 Blackwell Publishing Ltd Journal of Nursing Management, 2012, 20, 152–158

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Dual supervision The characteristic of this type of supervision is that a group is led by two supervisors. The supervisors complemented and supported each other in examining new ways of supervising: Ôwe have learnt this from each otherÕ, and they feel safe with Ôa practical perspectiveÕ. The supervisors reported that they functioned as a physical bridge between theory and practice. This made it necessary for the supervisors to learn about each other and develop ways of communicating easily: ÔSometimes I can be a bit withdrawn in order to let the nurse speak firstÕ. Problems that can hamper further cooperation might be a lack of planning or that the supervisors have different employers. The supervisors shared basic values on supervision and learning and a caring culture formed a common ground for both. Furthermore having two perspectives facilitated the creation of an open and permissive atmosphere and provided a stimulus for processing and analysing the patient narratives that the students brought to the session, which can further improve the supervision. In order to develop their roles, the supervisors must test new ideas or methods and Ôdare to failÕ (i.e. dare to expose their own weaknesses or to form their own opinions). The supervisors expressed that courage to do this could be considered to be the way to become secure in their role as supervisors. Working in pairs requires close cooperation and mutual trust. Both teacher and nurses expressed concerns that there is a risk that one supervisor could become the dominant party, so the joint reflection after each supervision session is important in order for both of them to gain some individual space: ÔBeing as we talked about this a little, was it good? Did it go well? Could we have done this otherwise? ÔWas I too dominant or did you have a chance to say what you wanted to say?Õ

Reflection as learning support The supervisors stated that reflection is the most important aid for learning. Supervision provides the opportunity for reflection and teaches the student to reflect at the same time: ÔIf we do not succeed in questioning their way of doing things, it is not supervisionÕ. The supervisorsÕ questions stimulate the students to think in order for them to be able to develop and gain a greater understanding of the patientÕs situation. The supervisors found that reflection occurs simultaneously both in the supervisors and in the students, starting with the patientsÕ narratives and the studentsÕ ª 2012 Blackwell Publishing Ltd Journal of Nursing Management, 2012, 20, 152–158

questions and thoughts about them. This means that reflection partly becomes a new way for the nurses to relate to their own activities. At the same time, reflection becomes an aid to help make words tangible and to develop the embedded knowledge in care practice: ÔYou gain a completely new view of the patientÕs perspectives. You need to question it... itÕs useful for me that my experience is used in a reflective wayÕ. The supervisors indicated that it is important to show the students that they must reflect on their own and that reflection must always be part of their approach. They needed to be open-minded, listening to the patientsÕ narratives and then formulate questions focused on the patientÕs lifeworld. The so-called Ôhow questionsÕ may open up for new ways to view a patientÕs situation and can provide the students with enlightening experiences. The supervisors emphasized that this is a type of detective work. The supervisors suggested that they can sometimes stimulate reflection by linking together a studentÕs thoughts with those of another or help someone put words to their reflections by linking these to what someone else has said. The supervisors found that, in this way, new thoughts and ideas were created in the group, thus generating further reflection. It is important to look at the narratives in depth and sometimes challenge the way the students think in order to see what happens. In the reflection work, it is possible to correct misunderstandings about meanings, which can be based on experiences from care practice, and help the students to become conscious of their prejudices. By considering the reflections it becomes apparent whether more knowledge is needed. The students gained an ideal picture of encountering a patient, how they are to approach a patient and how a caring relationship is created from the supervision. The supervisors found that this can generate feelings of security and confidence in them. Supervision also provides the students with tools to be able to argue on behalf of a patient and to help to see things more clearly, as their task is to protect the patient. The supervisors indicated that reflection is a natural and central part of supervision and that Ôwithout reflection, there is no supervisionÕ.

Interweaving caring science with the patientÕs narrative The supervisors proposed that interweaving becomes most noticeable when expressions and concepts used in caring science are applied to the patientsÕ narratives. The teachers found that this approach was positive in 155

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supervision as Ôthe concepts can naturally be found in the narrativesÕ and Ôthey appear to be an integral part.Õ The students are emotionally close to the patients, so supervision is concerned with what is Ôhere and nowÕ and what feels important for them. The supervisors found this stimulates their learning processes. By using nurses to guide the students, the latter gain access to concrete knowledge-based experiences. Scientific knowledge in caring practice attends to what is good in care, so that knowledge is very important for the studentsÕ education. One supervisor stated that Ôit becomes apparent in the supervision sessions that theory is part of the caring realityÕ and that Ôif you learn to recognize the concepts, then of course you can be freer in your roleÕ.

The student as a learning subject The supervisors aimed to follow the studentsÕ reflection and learning processes; their attitude is characterized by listening. This means that supervision does not always start in a patientÕs narrative and can instead start with the studentsÕ thoughts. The supervisors found that the studentsÕ are sometimes strongly influenced by seeing patients suffer, and they might see supervision as a Ôbreathing spaceÕ where they have the possibility to express things that otherwise might be considered difficult to cope with. In order to find a studentÕs motivation for learning, supervisors need to listen intently, be patient while listening and not force the student to reflect. They must support him or her in order to be able to hold emotions that may be difficult, for example, thoughts and feelings about a patientÕs suffering and own experiences of difficulties in care. This is a strength that the students need to develop in order to dare to encounter the patients lifeworld the supervisors mean. When dissatisfaction, irritation or other forms of negative expressions occur in a group, it is important to make a break and remedy what is disturbing the group and their learning process. The supervisors find that it is important in such a case for the supervisors to be able to understand the studentsÕ body language. One supervisor emphasized the importance of being aware of the studentsÕ lifeworlds so that they do not confront them with something for which they are not sufficiently mature. The supervisor can also, in this case, be helped by understanding body language, listening to the studentsÕ words and noting their actions in order to find the right balance when to put a little pressure on them and when to merely be there for them. 156

The learning environment of supervision A learning environment is, according to the supervisorsÕ experiences, multifaceted and characterized by an attitude that is concerned, engaging, confirming, stimulating, creating pleasure and is creative and permissive. The balance between laughter and seriousness is central. The learning environment is dependent on the supervisorsÕ ability to represent the caring science perspective through the scientific and the lifeworld perspectives. The aim of the supervisors is to stimulate the studentsÕ interests and make them part of the patientÕs narratives. This forms the basis for an active learning experience characterized by emotional commitment. This, however, requires that the students needs are being met and that they are confirmed in their understanding. The size of the group plays a major role in this case, being as too big (over eight) a group can be an obstacle for learning as it becomes difficult for the supervisors to pay equal attention to all the students. The supervisors observed that the group dynamics, the studentsÕ individual commitments and the atmosphere are thus of great importance, and one of the supervisors stated that because of this they cannot choose the supervision method before the session. Instead, in order to get the group started and keep the fire burning, it is a better to have a repertoire of different methods. Taking turns to speak is a major feature of supervision and provides the structure of the sessions. ÔTaking turnsÕ is used at the start and at the end of a session, as it invites everyone to be active and participate. The quiet students are given the opportunity to talk and the talkative ones learn to listen. Taking turns helps to clarify what is to be learned and is used as an aid to articulate feelings and plays an important and obvious part in the closure of a session.

Discussion The aim of this study was to describe the significance of supervisors working together in supporting the learning process of nurse students through reflective caring science supervision. In order to gain knowledge of the experiences of the supervisors from a lifeworld perspective it was thus natural to investigate the supervisorsÕ lifeworlds through interviews. The group interviews provided a rich material that was of use for the individual interviews in order to gain more in-depth knowledge about some specific questions. We believe that the chosen method has provided us with rich data, with rich variation of experiences of the phenomenon in ª 2012 Blackwell Publishing Ltd Journal of Nursing Management, 2012, 20, 152–158

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focus. This is important for gaining an essential structure of the study phenomenon (Giorgi 1997, Dahlberg et al. 2008) and is important for the opportunity for generalisations.

From dual to united supervision According to the results, dual supervision provides unique possibilities for interweaving and developing theory and best practice. However, having two supervisors in one group requires sensitivity, respect and responsiveness. If not, there is a risk that the supervision becomes divided and results in confusion. It is apparent that the supervisors must make a conscious effort to create a balance and allow each otherÕs specific competence to have its place in a specific situation. If this is done the students can gain a greater understanding of the patientÕs situation. When supervision takes place in harmony, it is perceived as being united. This can be likened to what van Manen (1993) calls, Ôthe tact of teachingÕ, even if he has not studied it in a dual teacher role. We maintain that a united supervision creates a need for openness and sensitivity towards each other, towards the students, towards the caring sciences and its practical application in care. Two supervisors create possibilities for reviewing and analysing their own practice, which becomes apparent in the results. For a teacher, such supervision gives access to vivid stories that can enrich their theoretical teaching. Teachers also become aware of the difficulties in applying theory into best practice. For a nurse, such participation means that they can review their own practice from a student and a patient perspective. Research has shown that when clinical supervision meets educational supervision, several anomalies are brought to the fore, benefiting the bringing together of the two discourses (Cornfort & Claiborne 2007). Our results show that both parties gain from their supervision. The question is, however, whether united supervision also enables implementation of caring science and a reflective, critical approach to clinical practice, towards which there are some tendencies in our results. The benefit of the reflection model for promoting learning has been pointed out in some research into reflection (Gibbs 1988, Mezirow 1991, Johns 1999). The results from the present study demonstrate the importance of not limiting oneself to a given model but being open and responsive to what emerges from the supervision session, so that the reflection does not follow any given steps but is instead a sort of tactful didactics. The aim of the reflection is to interweave theoretical and practical knowledge with the studentsÕ ª 2012 Blackwell Publishing Ltd Journal of Nursing Management, 2012, 20, 152–158

experiences of care. The results demonstrate the need to be flexible towards the student, the patientÕs narrative and towards each other as supervision thus makes the application of a strict supervision method impossible (Gadamer 1989, Ekebergh 2005). If supervision is based on a lifeworld perspective, the students are helped in their development towards becoming professional caregivers with a clear focus on the patient (i.e. a caring science approach). The results show how vital it is that the supervisors are able to lead reflection based on the patientÕs story in such a way that all students are affected and feel included in the group. The supervisors emphasized the importance of using the studentsÕ emotions and feelings in order to initiate a beneficial reflection session. According to McQueen (2003), it is essential that the students practice emotional intelligence in order to improve their understanding of themselves as well as of others and to be able to form successful human relationships. Our study demonstrates a model in which studentsÕ inner challenges such as emotional intelligence is given an arena for reflection and discussion and that it is important that the students are confirmed in their understanding of their own lifeworld if they are to be prepared to experience the patientsÕ lifeworld. The results of our study show that negative emotions, such as frustration, fear and anger with a patientÕs situation and his or her given care evokes personal commitment and constitutes a driving force in the learning process. It is thus important to make use of this in the supervision sessions. The size of the supervision group affects the possibility for creating a learning environment. The results also show that if the supervisors feel insecure, their responsiveness toward the studentsÕ lifeworlds is reduced. We thus maintain that the supervisors must themselves receive supervision on their supervision roles.

Conclusion and implications for nursing management Several researchers have shown that reflection is important for studentsÕ ability to gain theoretical and practical caring science knowledge. A unique aspect of the present study is that the student groups were supervised by two supervisors, which provides unique opportunities for interweaving theory and practice. However, this study shows that there are certain necessary prerequisites for gaining this positive experience. The conclusions of our findings are thus as follows: 157

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• Clinical supervision is important in order to acknowledge the studentÕs lifeworld by using both a theoretical and a practical perspective. • Supervising in pairs requires a sensitive interplay between the two but provides unique possibilities for interweaving and developing both theory and practice • A lifeworld perspective facilitates responsiveness and sensitivity towards both the student and the methods used in supervision • A potential, which is inherent in caring science, emerges once students, as well as supervisors, use scientific definitions and terms when processing and studying the patientÕs story more closely. We recommend that more projects are carried out in nurse education where two supervisors (a nurse and a teacher) work together to develop possibilities for interweaving and developing both theory and practice and that the effects of this are studied.

Acknowledgement This project was financially supported by the Council for the Renewal of Higher Education in Sweden.

Source of funding The Council for the Renewal of Higher Education in Sweden and Linne´ University of Va¨xjo¨, Sweden.

Ethical approval This study, which was performed in 2006, conformed to the principles outlined in the Declaration of Helsinki (World Medical Association 2005) and the Swedish National Board of Health and Welfare (2003), and to the condition stipulated by the University management that the informants were given the opportunity, both orally and in writing, to consent to participate in the study.

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