Nurses’ Experiences of Process-Oriented Supervision—Acquiring New Approaches to Demanding Situations

Background: Providing nursing care for patients and relatives requires a great effort from a nurse. It is therefore important for the nurse to have the opportunity to reflect on the caring acts included in process-oriented nursing supervision (PRONS). The overall objective of the nursing supervision is to support the professional development identity, competences, skills and ethics in different situations in nursing care. Aim: To investigate nurses’ experiences of the model of purging, playing and learning (PPL) according to Eriksson theory in a (PRONS) related to strengthen safe care, quality and professional development. Method: A qualitative study with individual interviews and the data was analyzed using qualitative interpretive content analysis. Participants: All eleven registered participated nurses were from southwestern Sweden and worked in different hospital units. Ethical Considerations: The study carried out in accordance with the ethical guidelines laid down in the Helsinki Declaration and according to the recommendations of the regional ethics committee. Findings: Three categories were identified, valuable purging in the process, responsive playing and awareness of learning. The study found that by participating in PRONS the nurses had developed new approaches with different “tools” when difficult situations occurred in daily nursing practice. Conclusion: PRONS with the model PPL has an important role to support nurses in daily nursing practice. The study highlights that there are residual successful effects after PRONS for the nurses in managing care situations that experienced strengthen quality in care and professional development.


Introduction
Nurse's relationships are unique with patients, and the relations are close. The nurses provide care of both body and soul; this requires understanding of the uniqueness of others as well as the nurses themselves [1].

Background
A purposeful tool to help nurses to gain self-knowledge and insight is reflection [2]. Result from studies shows that nurses who have taken time to reflect on daily experiences provide enhanced nursing care, have a better understanding of their actions and develop their professional skills [3]. A study with four experienced nurses discovered advantages from reflection to develop and mature professionally. The reflection becomes a tool to promote the courage to meet needs from patients and to help nurses to empower [4].
The overall objectives of the nursing supervision are to use reflection to support the professional development, strengthen professional identity, competences, and skills [5]. Likewise, strengthen the ethical consciousness while managing care situations in nursing [6] through participation in process-oriented nursing supervision (PRONS). Systematic and vocational guidance was used as an educational model in nursing. In this model personal, occupational and patient-related situations identified, processed and linked through self-reflection, peer review, and support, as well as deepening and widening perspectives [7]. Clinical work can be improved by placing the nurse in a supportive, trusting and respectful relationship with a colleague, in which the nurse can reflect on himself/herself in order to develop skills and competence [8] [9]. Attending PRONS can provide increased patient safety and increased health care [10]. PRONS is a model with a pedagogical process where clinical experiences are situated in a professional context, based on nursing theory perspective [5]. The theoretical perspective can make it possible that nurses give the opportunity to become more aware and able to relate to different caring situations. In PRONS different reflection methods are used, for example [11] which is a method of reflection that tries to clarify the situation, to articulate thoughts and feelings concretely. Gibb's [11] offers support to understand feelings and thoughts by analyzing what had happened and critically formulate an action plan. Another reflection method was Orlando's [12] where the reflection was based on what the supervisee saw, thought, felt and did. Yet, another method was KASAM [13] where reflection can provide an opportunity to gain a feeling of being in a context, of being strengthened and confirmed in their professional role and in their nursing work. Difficult situations may become more comprehensible, manageable and meaningful through such reflections [8] [9].
Ethical reflection, it has been determined that it will be of great benefit to both patients and healthcare professionals. To reflect on one's work leads to better working relationships, health and engages employees to become better in their profession by providing the best possible care [14], as well as more personalized care with a better connection to the patient and relatives [15]. PRONS is usually a process over 1.5 -2 years. The PRONS group consists of Between 5 -8 participants who meet for 1.5 hours, normally every second week. Each meeting organized in the same way. The supervisor is a nurse with a specific education in supervision and is responsible for the supervision. In the supervision the individual had possibility to reflection according to the model with three steps: purging, playing, and learning (PPL) by Eriksson theory [16] and experiences and reflections on thoughts and feelings were shared. A social network created by activities of affirmation, trust and identification. The process goes on in the play were participants practice and try different solutions according to Eriksson theory [16]. Where various activities are practiced and thoughts, feelings, actions and situations are tried out in order to get possibilities to develop a new, wider and deeper understanding of care activities. Skills learned in the play can be the discovery of power, the finding of intrinsic resources and the making of conscious choices regarding care. In the last part of the process, learning creates change and development where the individual better can understand themselves and others. Furthermore, it may create quality improvement of the care situation for the patients and those close to them [16].
In Arvidsson's [9] study, ten nurses describe the residual effects 4 years after participation in PRONS as: a feeling of being happy with their work, their knowledge and their skills; self-confidence in caring situations; personal development; awareness of the value of receiving PRONS and professional loyalty. It is of great importance that nurses develop their ability to deal with complex caring situations and regular process-oriented nursing supervision. The group provides an opportunity to strengthen this ability [6] [7] [16].
Nursing supervisors describe the importance that the supervision process has a clear structure and that one of their supervisory tasks is to maintain the structure as well as to create an atmosphere of honesty, acceptance and empathy [8] [17].
The supervisor's mission was for the participants to support and encourage reflection, promote dialogue between the participants and keeping the structure without including their own normative views. An experienced supervisor can identify the core of the discussion held during the reflection meeting, where participants fee safe if a conflict situation occurs [17]. The supervisor had an important role in the group and significantly affects the reception of the reflections in the group calls and the group outcomes [17] [18] [19] [20] [21]. Another important factor in PRONS is the balance between support and challenge that enables the process to develop within the group [6] [8] [17]. The importance of highlighting nursing situations, based on a scientific frame of reference for daily nursing practice, in process-oriented nursing supervision in the group of nurses has been described in several studies that have the same model of PRONS and evaluated through open interviews and focus groups [6] [22] [23]. The scientific reference for clinical supervision describes the meaning of the concepts of health, disease, human, nursing and nursing care from a nursing perspective [24].
The purpose was to investigate nurses' experiences of the model of purging, playing and learning (PPL) according to Eriksson theory [16] in process-oriented nursing supervision (PRONS) related to strengthen safe care, quality and professional development.

Aim
The aim of this study was to investigate nurses' experiences of the model of purging, playing and learning (PPL) according to Eriksson theory in a (PRONS) related to strengthen safe care, quality and professional development.

Design
The study used a qualitative descriptive method, where the nurses who had completed PRONS interviewed individually by the first author (LC) about the experience of having participated in the supervision [25]. Questions were asked on the basis of Eriksson model [16] about the reflection in PRONS about purging, playing and learning, by which the analysis was performed with an encoding scheme in advance [26]. The questions were tested with a pilot test with three nurses and none of the questions has to been changed.

Sampling
The study was conducted in southwestern Sweden among nurses who work in different hospital units. Inclusion criteria were nurses who spoke and understand Swedish and had participated in PRONS for at least 1.5 years. Exclusion criteria were that it should have been no more than 5 years since they had ended the PRONS. Active nursing supervisor who supervised in hospital asked nurses that they had supervised, by mail from their groups who finished participating in PRONS. The nurses who accepted to participate in the study where phoned by LC to determine the time and place of the interview and given verbal information of the study. Eleven nurses, aged between 33 -58 years (mean 50) who had worked as nurses for 7 -37 years (mean 22) agreed to participate.
Eleven nurses participated from different PRONS groups. The participants were nurses who had participated in the PRONS. 1 -5 years (mean 2.5) after the end of their participation in PRONS. They have had different nursing supervisors, but they had all used the same PRONS model.

Procedure
Data collection applied as qualitative interviews and finished during the year 2014 [25]. All participants interviewed by LC at a place at the hospitals chosen

Analysis
The eleven interviews transcribed verbatim by LC and analyzed by all the authors using deductive interpretive content analysis [26] [27]. The text was interpreted based on Eriksson's theory [16]. The analysis focused on the interpretation of the texts, as qualitative content analysis used particularly in the behavioral, human and health sciences. After the interviews were transcribed verbatim, the analysis process started. In which the authors were reading the entire interviews texts several times in order to get the full picture. Eriksson's theory [16] was used in the interpretive analysis of the in advance encoding scheme of the three steps purging, playing, and learning in PRONS [16] [26] [27]. This model played a major role and headed up both subcategories and categories in the analysis.
Phrases or sentences containing information of relevance were sorted out.
Codes that dealt with the same thing were organized under the same subcategory. After that, the authors compared their data and reached agreement. The subcategories were assigned to 3 categories (see Table 1). The trustworthiness of the analysis was confirmed by the close description of the analysis process and the corroboration of the results by quotations from the informants [27].

Ethical Consideration
The study was carried out in accordance with the ethical guidelines laid down in the Helsinki Declaration [28] and

Findings
The analysis of the interviews resulted in three interpretive categories with eight subcategories ( Table 1). The categories include the meaning of PRONS process and ties to the selected theory. Quotes were used from the informants, cited as participant's numbers 1 to 11.

Valuable Purging in the Process
The nurses have experienced that participating in PRONS gave them the possibility to reflect on their own situation, to reflect on events where they may not have acted correctly and needed to talk about it and to reflect on their thoughts and feelings. Step 1-Valuable purging in the process To get support and feel secure To be part of a group To be strengthened in the profession Step 2-Responsive playing To get the opportunity to see one's own development To gain knowledge Step 3-Awareness of learning

To Have Time for Reflection
When the nurses took part in PRONS, they have experienced the feeling of having time to reflect on thoughts and feelings that arose in the nursing situations where they might not always have done the right thing. They needed to tell their stories to colleagues who understand the nursing conditions. Likewise, they highlighted the experience of having time to reflect on feelings and thoughts on the perceived, both for their own experience but also together with the other participants in the group.
The fact that you could really present a situation and express yourself on the subject, taught me not to go and dwell on things while working (Participant 6).

To Give Vent Verbally
In daily nursing practice, the nurses experienced having no time to express their feelings. The nurses described the importance of having the opportunity to give vent verbally, to put their experiences into words. It described being of great importance to talk about themselves with colleagues and to be able to talk without being interrupted.
I do not think you can get enough PRONS; it is probably both valve and input … it was rewarding and I was being heard, I got to say what I thought and I got straight answers (Participant 4).

To Raise Ethical Situations
It was very valuable for nurses to be able to discuss ethical issues. The talk in the PRONS group was about pointing out care situations that experienced as right, wrong, good or bad, and also about receiving and providing different viewpoints. Through discussions, the participants' ability increased in understanding the possibilities in future ethical situations in health care.
Big and difficult questions about ethics, especially concerning seriously ill children … very useful to get different views and different ideas about various situations (Participant 6).

Responsive Playing
When the nurses took part in PRONS they have experienced to find a place of trust, which offered them the possibility to share and listen to others' care situations. Through a variety of activities, the nurses described experiences of strength when tried out their thoughts and feelings in different experienced care situations in nursing.

To Get Support and Feel Secure
The nurses described they experienced that they could observe situations from a different point of view. Furthermore, nurses described the experience of reflecting on own experiences from other participant's experience in similar situations.
This was described by the nurses' as a positive experience, an aspect that they were able to both give and receive support and security from each other through their participation in PRONS. In addition to this, the nurses described that the confidentiality in the group create security and they dared to express their feelings.
The supervision also gave the answer that what you do is enough-You cannot do everything (Participant 6).

To Be Part of a Group
The nurses described that they experienced feelings of belonging, that they along with colleagues in the supervision group formed a community. They also described that they felt that it was positive that they shared situations of care. The fact that each of the participants felt that they belonged to the group was an experience described by the nurses. Participation also gave participants a greater opportunity to evaluate their own and others' contributions.
I could go to the supervision with negative thoughts, and I remember that I walked away with positive thoughts, some ideas were new and some had changed … I got to both process and think about what you had done and how to do things differently, and also why people sometimes make the choices that they make…share with the others, as they are in the same situation (Participant 8).

To Be Strengthened in the Profession
By participating in PRONS nurses described experiences of being able to experience both their own and others' development in the nursing profession. In reflecting and listening to colleagues they improved their competence, became better nurses and more aware in their professional capacity. The nurses also described the importance of promoting deeper thoughts in PRONS using a variety of exercises.
… You get to … both work and think things through … what has been done and how to do things differently and why you sometimes choose to do what you do (Participant 8).

Awareness of Learning
In the process of raising awareness and playing in PRONS, nurses described experiencing a learning process regarding knowledge and development, both at a personal and at a group level.

To Get the Opportunity to See One's Own Development
In PRONS nurses described experiences of opportunity to dispassionately reflect on various care situations, and through this, they were able to see their own development. To have this opportunity to express themselves in a group configuration rather than in normal conversation form, was experienced as very positive, and important.
… You learn a lot about how to deal with the situation through the others. Yes, you become better professionally (Participant 2).

To Gain Knowledge
Through active and reflective participation in PRONS, the nurses described experiences of learning different ways in which to respond to patients and colleagues. They experienced improving their knowledge through reflection, adding another layer to their nursing work, and they gained greater knowledge by linking theory and practice. The nurses had learned through the different activities how their feelings and thoughts could be activated in a nursing situation. By their own knowledge and experience, the nurses could see how they could protect themselves so that they not would be affected negatively.

Discussion
The first author (LC) did all the eleven interviews and did not experience any differences between the two occasions regarding the answers from the nurses.
The authors participated in both of the two occasion's analysis process. They have also discussed their interpretations of the result. Quotations have been presented to enable the reader to follow the analysis and interpretation process [26] [27]. The analysis process was accomplished according to Erikson's theory [16] which was used as a selected model that affected the choice in the analysis of the three steps where purging, playing and learning describe the categories. This model gave an analysis of deductive steering, but this has clearly been elucidated. The authors handled their own pre-understanding through awareness-raising discussions and by reflecting on it when reading the interview texts.
If focus groups were used instead for interviews, the study could have shown a result with a different perspective because of the group process. Despite this, the eleven nurses with continuing experience of PRONS who participated were judged sufficient to form the basis for a qualitative descriptive report of a result PRONS was a model where nurses despite different situations in the health care, have time to reflect of daily situations in the close nursing situations. Reflection in the participation was in an arena with security and feeling safe to express feelings and thoughts, which strengthened the nursing profession [5] [16].
A model that most nurses should be offered to develop as nurses said Tveiten [7]. The clinical nursing practice in daily work would be strengthened, stimulated and given a maturity in their professional role, on an ongoing basis by nurses' participations in PRONS [8] [9].
In this study, nurses describe their experiences of participating in PRONS up to five years after that participation ended. Through participating in the PRONS the nurses had possibility to be in a group process, over a regular and longer period, allowing time for further reflection, possibility to talk without being interrupted and reflect on ethical situations.
The results suggest that there are residual effects several years after their participation in the PRONS was completed. None of the nurses remembered that it was something negative to participate in PRONS.The nurses achieved a well-being of participating in PRONS and developed their nursing. They also expressed that it was instructive both to be the person in focus and to be the one who listened to others in the group. In the same way, [5] has described the process in PRONS. For the nurses care means various forms of being aware, the play and learning, to change, sustain, launch and support the health processes within the caring [16]. Each PRONS group had their own supervisor, they met regularly and had rules about how the supervision should be carried out. In the study's result, it is showed that the nurses felt secure, received support and could rely on their group, this also confirmed by Severinsson [5].
Several studies confirmed the result that in the coaching of awareness the nurses were given the opportunity to tell their own version of situation verbally [ [30]. It is important that the nurses allocate time to reflect on their situations, it correlates well with other studies [12] [13] [16]. The focus was on the nurses care situations that they had experienced as difficult or in which they felt they had not been successful, as confirmed in other studies [23] [24] [29]. Several earlier studies proved that with this study the participants were given the tools they needed in order to be able to give care, the opportunity to ask questions, to process their own reflections and those of others in the context of various nursing situations. They had a feeling of strong peer support and sharing by listening to the person who was in focus. Through the playing and support that was given, the fellowship was strengthened for the participants [ [31]. Residual effects of participating in PRONS were still present even after several years [5] [10] [29]. Another consequence as also described both in this study's result as in several studies that active participation in the group, connected with the men-toring and the play, was a learning experience. The learning meant that the nurses were aware of their own development [9] [16] [29], also of their increased understanding of the patients and the quality of their nursing in clinical practice [6] [7] [16] [23] [24] [30].
Threat in today's nursing practice to reflect was lack of time as a factor that inhibits the ability to conduct discussions, when nursing staff do not prioritize non-patient-oriented tasks, the nurse felt that their main task was to be with the patients [31] [32].
Methodological considerations taken into account in this study were that there were only a few participants. If we had interviewed several more nurses in this study, we might have got a broader material to analyse but probably we would have the same result.There were only female nurses that participated, which reflects the overall population in health care. The nurses were well prepared of information of the study for the interview with an information letter, phone calls and at the time for interview.

Conclusions
This study demonstrates that the nurses experienced that with PPL in PRONS they developed both professional and personal effects that remained several years after its completion. For nurses, it meant acquiring a new approach to demanding situations with patients and relatives. They had found and embraced competence to manage and respond to different nursing situations in daily practice by developing their work as nurses. None of the participants had experienced any problems with the PPL in PRONS as they remembered. However, they could at some time have found it difficult to get time to participate as their unit was understaffed.
This study highlights the need to give nurses the opportunity to participate with PPL in PRONS recurrently so that they are able to provide high quality in nursing care. Furthermore, so that nurses will have improved conditions to carry out and develop nursing competence in their professions. The PRONS increases the prospects for coping with care giving work and can reduce employee turnover, as nurses felt supported and confirmed.

Further Research
In the future, it is also necessary to conduct more intervention studies in the field.