The Benefits of Person-Centred Clinical Supervision in Municipal Healthcare — Employees ’ Experience

Satisfied employees in healthcare services who have opportunities to develop their professional competence by reflecting on professional challenges play an important role in the quality of care. The aim of the present study was to describe the employees’ experience of the benefits of participating in a personcentred clinical supervision setting. The supervision, guided by a professional supervisor, was carried out with a group of six dayand night-shift municipal healthcare professionals for a period of four months during their mandatory work hours. Data were obtained from written individual evaluations and group interviews shortly after the last session and again twelve months later. The results showed that the participants experienced that their internal resources and coping skills had been strengthened by the supervision. They developed abilities to meet the challenges more constructively than before. New understandings gave them the opportunity to alternative actions in practice. Further intervention studies of person-centred clinical supervision must focus on such clinical outcomes as patient safety and professional development.


Introduction
Satisfied employees play an important role in an organisation's success [1].Job satisfaction in healthcare services relates to the beliefs and emotions that individuals have about their work and their job [2] and is crucial to the quality of care [3].However, employees of municipal healthcare services face emotionally demanding tasks on a daily basis.Addressing complex ethical issues can be inspirational and motivating, but it may also lead to stress and poor experience of coping at work [4].In order to promote coping in daily work, there must be support and opportunities to develop professional competence.Clinical supervision may provide this opportunity by reflecting on professional challenges [5] [6] and ethical dilemmas [7].Begat, Ellefsen and Severinsson [8] assumed that the supporting of nurses by clinical supervision could have a positive influence on their perceptions of well-being.Therefore, it is important to provide conditions for easy communication for healthcare employees.This might not only enhance job satisfaction for care providers, but also lead to better quality of life for care receivers [9].
There are many kinds of approaches to clinical supervision.According to Tveiten ([10], p.17), it is "a formal, pedagogical, relational enabling process, related to professional competence.Relationship and dialogue are central aspects.
Supervision is based on theory and humanistic values, has a normative, formative and restorative function".The approach in clinical supervision used in the present study is based on existential/phenomenological tradition and influenced by person-centred theory [11], with elements of gestalt theory [12], which is a process between individuals as well as within the individual.The supervisor's role is grounded in Rogers's client-centred approach, also called the personcentred approach [13] [14].In a person-centred process, the function of the supervisor makes it possible for the supervisee to achieve emotional release in relation to a problem and to think more clearly and more deeply about her/himself and the situation.The supervisor is not the expert, but facilitates the supervisee to release her/his own problem-solving forces.
In Buus et al. [15], the care providers in psychiatric care considered clinical supervision to provide limited improvements to their clinical practice.However, neither management nor the staff prioritised participation in clinical supervision settings, which might have undermined its potential benefits.Häggström and Bruhn [16] showed that employees responsible for the care of older people felt positive towards the idea of participating in clinical supervision, but they felt that the management did not create the conditions needed to carry out supervision during work hours.The authors concluded that clinical supervision had to be integrated into work life.In an attempt to develop the quality of care in health practice, the management of municipal healthcare services of older people in the present study encouraged clinical supervision, which was carried out during the participants' work day.The aim was to describe the employees' experience of the benefits of participating in a person-centred clinical supervision setting.

Method
The study was conducted in a qualitative descriptive approach focusing on individual stories about personal experiences, which should be seen as unique and never generalised [17].

Participants and Context
The sample was six day-and night-shift health professionals (two registered nurses, one occupational therapist and three nurse-aids).They were all women aged from 44 to 56 years (median = 50).Their duration of work experience in health and welfare care service varied from 5 to 30 years (median = 17.5).They were invited to participate by the management.They provided healthcare services to older people in a small municipality in central Norway, but the occupational therapist also worked with younger adults.None of them had participated in organised clinical supervision before.
The clinical supervision was carried out through group sessions guided by one professional supervisor.The participants received 1.5 hours of supervision every other week for a period of four months during their mandatory work hours.
They were encouraged to address situations from their everyday work that they wished to reflect on more closely.At each session, one of them usually told her story by sharing feelings and thoughts about the situation.The supervision and group discussions proceeded further on the basis of what was reported.

Data Collection and Analysis Procedure
Data were obtained from written individual evaluations and group interviews shortly after the last session and again twelve months after the last session.The written individual evaluations and the interviews emanated from the main question: "What have you discovered or been more aware of in relation to your everyday work?"To ensure the trustworthiness of the study, the authors' findings were also discussed and validated in the second group interview.Sandelowski (2010) argues that qualitative content analysis is a dynamic form of analysis that identifies and summarises data that provide knowledge and insight.This process involves a systematic search for the codes that are generated from the data.Accordingly, the data were analysed by qualitative content analysis inspired by Graneheim and Lundman [18].At first, the transcribed interviews and participants' written texts were read through carefully several times to gain an overall understanding of them.The next step was to split the text into meaningful units, that is, words, sentences and paragraphs of text that were linked through their content and context.The two authors did those two steps independently.In the third step, the text was labelled with codes.Codes are meaning units that permit new reflections in a different way, and they have to be understood in relation to the context.However, according to Graneheim and Lundman [18], the development of categories is the core or main issue in content analysis.The fourth step was therefore to create categories.The categories refer mainly to a descriptive level, and the content could be seen as an expression of the manifest content of the text.Three sub-categories were formulated: increased security in themselves, more awareness and reflection than before, and accepted that their work involved challenges and ethical dilemmas.In the next step, the text was read from code to categories and vice versa.In the analysis process, it is important "to go back and forth", but the most important task is still to point out the manifest content.After formulating the results of the first interview, the second group interview with the participants was carried out.
From the interview, the earlier findings were filed into two categories (see Results).Finally, a theme represented a thread of meaning through which the categories were established on an interpretive level.

Ethical Considerations
The Norwegian Social Science Data Services (NSD) approved the research project (no.31689).Participation was voluntary and based on informed consent.
The study was conducted in a familiar context where the participants were wellknown within the organisation.Therefore, it was important that the results were presented in a confidential and safe manner.

Results
After participants' validation, two categories with sub-categories emerged: 1) Clinical supervision contributes to increased professional competence, and 2) Clinical supervision contributes to the promotion of health.From those categories, the latent theme was created: Clinical group supervision contributes to personal growth and enhances the quality of provided healthcare services (see Table 1).This was done in a forward-backward process.

Clinical Supervision Contributes to Increased Professional Competence
The informants expressed that supervision strengthened their beliefs in their ability to handle challenges.When work experiences affected them emotionally, the opportunity for reflection in a supervision setting created new understanding and new knowledge.They emphasised the intervention of knowledge, in which they not only increased their awareness of what they already knew, but also gained completely new knowledge.

Increases Awareness and Confidence in Competence
All participants thought that the supervision setting had given them comfort and security to trust in their own competence and that each of them were important and responsible parts in the daily work of their organisation.
Table 1.Overview of theme, categories and sub-categories.

Sub-categories Categories Theme
Increases awareness and confidence in competence Those feelings of confidence in their own competence turned into feelings of professional confidence that were shown in their actions and in discussions at work."I have become more conscious of my own professional confidence... and am not accepting items I do not agree with".

Increases Ability for Reflection and Conscious Choice
The supervision process also helped the participants to reflect and make conscious choices at work.They were growing more aware and reflecting about the issues being expressed and on how different situations had influenced them and the patients.This made them ask questions like: "Am I competent to do this?"Their daily work involves many ethical dilemmas.Since the informants seldom had time or opportunity to discuss those dilemmas with their colleagues, the specific situations made them feel insecure and lonely.However, in the supervision setting, they felt affirmed and as though they were not alone: "Other colleagues experience the same dilemma as I do, and supervision would help in those situations"."Now I put ethical dilemmas into words, earlier they were hidden in my own head".

Increases Ability for Professional Collaboration and the
Use of Communication Tools After the supervision sessions, they also felt more open-minded to other solutions: "I feel well when I talk with colleagues within the same profession about problems due to my work.They may see it otherwise and may have other solutions … from other perspectives".
They expressed that they were listening and discussing professionally, without accepting ethical conclusions when they disagreed with them.Those talks within the same profession also made them more open to discussions with and listening to other professionals."Collaboration is important to me, being able to discuss to find solutions, also crossing professional borders".Supervision also increased the participants knowledge by asking control questions-"Is this ... what you mean?"-and being more flexible-"What can I do?Is there any other way to act?" In addition, they emphasised that the supervision setting had introduced many methods that could be used in daily work.
"We use many of the methods [from supervision] in facing patients and their families, students and colleagues.We listen, ask questions, examine our understanding, do not interpret any longer, and give confirmation".
They thought they had experienced many useful things that could be good tools at work.

Clinical Supervision Contributes to Promotion of Health
The informants experienced that their reflections and discussions of patients' situations and ethical dilemmas in the sessions offset their own stress and fatigue syndromes.There was also consensus that their increased awareness of reflections and ventilations benefitted the psychosocial work environment.

Prevents Stress and Burn-Out
The supervision setting enabled the participants to dive deeper into the situations by reflecting on them and airing them out.This not only improved their professional competence, but also their own health.They all thought that discussing situations, reflecting on them and feeling affirmed at work helped prevent stress."Getting it affirmed, maybe you were not able to do it otherwise anyway, having verification".Previously, their minds often were preoccupied by daily work situations when they got home, and sometimes they had difficulties sleeping.Now they could engage in family instead of work during their leisure time.
"Think it prevents what today is called being burned out".

Improves Psychosocial Work Environment
The participants emphasised that their frankness, "…getting better at directly saying what I mean, putting into words what I mean", and confidence in themselves and in the daily work situations led to their increased comfort in general discussions at work and not only in specific patient-related discussions.Before the sessions, it was possible to air something out during staff meetings, but it happened more randomly.They experienced their work environment as being more open-minded after the supervisory sessions.
"It does something about the work environment, it is getting better"."That we talk about a situation in general, getting aware and reflect and bringing closure to it in a way together".

Discussion
The aim of this study was to describe the healthcare employees' experience of the benefits of participating in a person-centred clinical supervision setting.The informants' descriptions emerged into the theme of "Clinical group supervision contributes to personal growth and enhances the quality of provided healthcare service".The theme reflects the interpretation of their descriptions of themselves as individuals as well as their interplay with colleagues within the same profession, other professions, patients and their families, and students.
All participants expressed that the supervision had given them comfort and security to trust in their competence and that each of them were important and responsible parts in the daily work of their organisation.The supervision also led to increased knowledge, which raised their competence.The participants described this as a completely new kind of understanding and knowledge.It occurred especially when the group discussions in the supervision setting led them to reflect about work situations that had affected them emotionally.In gestalt and person-centred theories, the paradoxical theory of change and awareness is central and may enlighten what happens in the process of supervision.Beisser ([19], p.77) has formulated that "…change occurs when one becomes what he is, not when he tries to become what he is not".According to Melnick and Fall [20], the freedom to choose new behaviour is what the paradoxical theory of change and the construct of awareness are about.Person-centred clinical supervision uses methods that are developed to increase awareness of the participants' own thinking, feelings, reactions and actions so that they can clearly recognise and see themselves and their choices.This awareness emerges through empathetic listening, dialogue and creative methods [21].The supervision setting focuses on the present by exploring the experience as it really is through a process of involvement and awareness of new understanding that leads to choice and action.
Expanded awareness creates growth and development, and the supervisee can choose behaviours that fit her/his expanded awareness.This can be referred to as nurses' professional autonomy [22].Weston [23] argues that professional improvement is a necessary precondition for nurse autonomy.This also provides a framework for augmenting clinical autonomy.
Further, the participants expressed that clinical supervision strengthens their beliefs in their ability to handle challenges and cope with demanding professional tasks.To be more confident of their expertise can be seen as positive, but if this expertise is lacking, this reassurance may not have a positive effect on the quality of care.Nevertheless, the present study shows that comfort and confidence in their own competence and increased awareness made them both more secure in action and more open-minded to new and different solutions.Some choice of actions were accepted and acknowledged, other times it was obvious to the supervisees that both their mindsets and attitudes needed to be revised.They were aware of their true selves.Harter [24] describes that authenticity is a concept, which means acting in agreement with one's emotions, values, thoughts tions.The group process in the supervision setting and that the group was multidisciplinary may have had an impact.According to Fay et al. [25], multidisciplinarity has a positive influence on a group's quality of innovations.Their find-ings showed that the clinical supervision made them more open to analysing and listening to others' experiences and assessments of professional challenges.Cooperation both within the supervision group and with other groups was rated as a positive opportunity to deal with professional challenges.They described it as increased portability for reflection and making conscious choices.
The participants found that the supervision strengthened their ability to cope with daily challenges.This again had a positive impact on the health situation.
After conducting the sessions, consensus was reached about the supervision's health benefits, i.e. by preventing burnout and improving the psychosocial work environment.Their work with patients in municipalities is often single-handed, with few possibilities to co-operate with colleagues in patient care situations, a factor that is of importance for job satisfaction [26].Burnout has increased in many countries, especially among healthcare staff, during the last decades [27].
In a study by Edwards et al. [4], community mental health nurses reported lower levels of burnout after clinical supervision sessions.Burnout is also connected to work atmosphere [28].Koivu et al. [29] found that the nurses who received efficient clinical supervision reported more job and personal resources and were more motivated and committed to the organisation than others who had not received it, and that supervision may be viewed as a preventive method for burnout.The informants expressed that receiving support and challenge from colleagues, both from the same profession and from other professions, affected the work environment positively.Ohlson and Arvidsson [30] found that clinical supervision had an impact on preventing negative effects of work-related stress and strengthened the ability to handle a stressful work situation.Support from the group strengthened self-esteem and promoted mental health.According to Rogers [31] [32], the task of the supervisor is to assist the person attaining the intentionality and health that is natural to each individual by making it possible to gain emotional release in relation to his problems.He claimed that self-actualisation or health may ultimately be defined as experiencing one's completest humanity.A person who becomes truly in touch with his/her inner self will move to positive action, fulfilment and self-actualisation.
Travelbee [33] claims that nurses have who suppressed their emotions too much and for too long are not able to meet the needs of their patients because their own needs have not been met.In our study, the supervision setting provided opportunities to release and support repressed emotions, consistent with thoughts about supervision, burnout and health.Pavlish, Brown-Saltzman, Fine and Jakel [34] found that many healthcare employees avoid talking about ethical problems because of factors such as fear of harming relationships, lack of continuity in care and lack of shared decision-making.They meant that this avoidance could lead to moral distress and burnout.According to Antonovsky's sense of coherence theory, humans with the resources of comprehensibility, manageability and meaningfulness have better chances of coping with the challenges of work life [35].Kitwood and Bredin [36] presented the person-centred care approach in healthcare, which was influenced by Rogers's client-centred theory [31] [32].However, to be in a person-centred caregiver role, the caregiver also must be able to have her/his needs met and to have opportunities for personal professional growth and development.That is, the caregiver must be met as a professional in a personal way.This puts demands on the individual employee, but also on the staff as a group and the organisation, including the leadership.Lynch et al. [37] state that person-centred nursing must be integrated with situational leadership theory to provide the individual level of appropriateness to support person-centred practice.In Edvardsson et al. [38], the results showed that job satisfaction as well as support from the organisation and the degree of environmental accessibility could predict perceived quality of person-centred care.That is, to be in a person-centred caregiver role, the caregiver must be in a work environment that gives opportunities for reflection and professional development [39].This requires creating a work environment that is characterised by employees perceiving themselves as active participating subjects able to identify and be aware of their internal and external resources [35].It is necessary to create a democratic and inclusive approach to practicing culture that gives space for implementing person-centred relationships [40].Accordingly, the person-centred clinical supervision allowed the participants in our study to improve their ability to reflect, communicate and be more empowered in their work environment.

Methodological Considerations
The participants in this study were few, only six persons, but they actively took part in the study over a period of four months in which they developed data for the entire period.The data were collected from written individual evaluations as well as group interviews.In the last interview, the participants increased and developed the data.This might indicate that the knowledge and awareness from the person-centred clinical supervision setting had been integrated into the individual participants as well as into the everyday work.Further, to ensure credibility, the participants also consulted our preliminary interpretation from the first interview in order to come up with the final version [41].Moreover, the participants were explicitly asked whether they had negative experiences with participation, which all clearly said that they had not.They were not randomly selected, and they might be more open-minded and positive towards quality changes and developments than others staff members.However, the study may say something about these six individuals' experience of the benefits of participating in person-centred clinical supervision settings.Then it is up to the reader to determine to what extent our findings are transferable to other contexts.

Conclusion
Communication and interpersonal relationships are essential to the quality of patient care [42].The findings in our study show that the inclusion of personcentred clinical supervision is an enabling process that contributes to those aspects and enhances the quality of municipal healthcare services.The participants experienced that their internal resources and coping skills were strengthened as a result of the supervision.They developed skills to meet work challenges in a more constructive way than before.New understandings gave them the opportunity to alternative actions in practice.According to change theory, this is not only beneficial to the individual, but also relevant to organisations in order to improve integration and holism.That is, making the work setting healthier may contribute to improving the overall practice.However, since there is still a lack of evidence on the effects of person-centred clinical group supervision [43], further intervention research must focus on such clinical outcomes as patient safety and professional development issues.

Implications for Practice
The process of person-centred clinical supervision supports professional competence, which in turn gives opportunities to improve the health of both the individual staff and the organisation.The process of person-centred clinical supervision also supports person-centred communication and person-centred care by supplying a holistic work-environment.However, when implementing personcentred clinical supervision, it is important that the management as well as the individual employees create conditions for participation.Besides integrating the sessions into work time, there is a need for person-centred clinical supervision education for the staff and students who provide the municipality healthcare services.
Clinical supervision contributes to increased professional competenceClinical group supervision contributes to personal growth and enhances the quality of provided healthcare services Increases ability for reflection and conscious choice Increases ability for professional collaboration and the use of communication tools Prevents stress and burnout Clinical supervision contributes to promotion of health Improves psycho-social work environment "I now see that I am responsible for my work, I'm influencing changes and I expect much from myself".At the same time, they became more aware of what they considered valuable and important: -"I have become more aware of my attitudes and values, what is right and wrong to me".The discussions in the group sessions helped them to place limitations in their own work: -"I have a higher ability to determine my own limits".
and beliefs.The awareness and acceptance of "what I am and what is" instead of "what should I have been and what should have happened" led to acceptance, security in action, as well as openness to discussion, reflection and new solu-