Clinical supervision and support for bridging programme students in the greater Durban area

Correspondence address; Padmini Pillay 5th Floor Desmond Clarence Building UKZN Abstract: Curationis 31(4): 46-56 Reviewed literature revealed that clinical supervision is a conceptually sound learning model, which, unfortunately, is flawed by problems of implementation. Some of the more glaring problems include limited emphasis upon problem-solving, lack of clear expectations for student performance, inadequate feedback to students, inappropriate role models in clinical settings and inadequately prepared clinical teachers. The purpose of the study was to explore and describe the nature of clinical supervision and support provided to bridging programme students in the clinical settings. Participants were drawn from three nursing colleges and 122 participants returned questionnaires. College 1:26,2% (n=32), College 2:15,6% (n=19) and the majority, 58, 2 % ( n=71) were from College 3. The participants were second year students in the Bridging Programme. Purposive sampling was used for the selection of the hospitals. The researcher purposively selected those hospitals offering the Bridging Programme. The students were randomly sampled. According to Bums and Grove (2001), simple random sampling is the most basic and most effective of the probably sampling methods. Data was collected by means of a questionnaire and a critical incident report. The questionnaire used in this study was adapted from the Manchester Clinical Supervision Instrument. The findings revealed that clinical supervision contributes positively to the academic, professional and personal development of students. Although there was support for clinical supervision by the nursing staff, time for clinical supervision was the main problem. Clinical supervision was viewed as time consuming. Clinical learning emerged as secondary to ward routine. The students functioned as part of the workforce and missed out on some important learning opportunities. Results also showed that some clinical supervisors were not adequately prepared for their roles and responsibilities; as a result there was no significant relationship between clinical supervision sessions and the acquisition of knowledge. The critical incidence revealed positive and negative experiences regarding clinical supervision and the support provided by clinical supervisors and clinical staff. There is a need for clear policies regarding clinical supervision, a structured and well monitored process of clinical supervision, building the capacity of clinical supervisors, and addressing the issues of use of bridging programme students as part of the workforce.


Introduction and Background
The concept of clinical supervision can be traced as far back as the time of Florence Nightingale, where experienced nurses p ro vided g u idance to less experienced nurses in their clinical work (Winstanley & White, 2003:3).According to Benoliel (1988:340), students need (a) a sense o f being cared for during the process of learning to care for others, (b) they need to feel that they are receiving support and guidance whilst dealing with clinical experiences in w hich they perceive themselves to be failures or incompetent at.Some o f these themes emerged in the study by Smith (2000:5), w hich em p h asised the need for psychosocial support over and above academic support.
According to Tiwari, Lam, Yuen, Chan, Fung and Chan (2005:299) clinical learning plays a crucial role in nursing education programmes.Not only does it provide opportunities for students to apply the theory learned in the classroom to the real world o f clinical nursing, it is also a socialization process through which students are inducted into the practices, ex p ectatio n s and re a l-life work environment o f the nursing profession.. P roctor (2001) reg ard s clinical supervision as having three aspects: normative, formative and restorative.
Clark, Jamieson, Launer, Trompetas, Whiteman and Williamson (2006:106) categorize clinical supervision into ed u catio n al su p erv isio n , rem edial supervision and mentoring.Educational su p erv isio n is o rg an ized clinical supervision taking place in the context of a recognised training programme.As well as providing opportunities for support and development, the supervisor also has to assess the supervisee's performance and report on this to others so that they can judge if the person m akes the grade for a p articu lar qualification.According to Clark et al. (2006:106) within educational supervision there is g en erally a clea r contract regarding who is reporting to whom, about what, and why.These authors state that in terms o f Proctor's analysis, the emphasis within educational supervision is generally on the formative aspect of the w ork.Each o f these aspects according to Clark et al (2006:106) may com e to the fore or rem ain in the background in clinical supervision, according to the circumstances.
Clinical learning is defined by Henderson (1995) as the m ode th at provides students w ith the o p p o rtu n ity to translate theoretical knowledge into the learning of a variety of skills required to give patient-centred care.It facilitates correlation of theory with practice in the cognitive, affective and psychomotor domains in the clinical setting for the students to reach acceptable levels of competence in these areas.Mthembu (2003) states that clinical learning is described as being at the heart o f professional education, as it provides a stu d en t w ith the o p p o rtu n ity to consolidate knowledge, socialize into p ro fessio n al roles and acquire professio nal values.Yet m ost professionals still seem to regard it as having connotations o f perform ance monitoring and management.They think it means having someone looking over your shoulder instead o f looking after you.
Learning in clinical settin g s is an important part o f the curriculum and accounts for approximately 50% of the pre-qualifying nursing program m e (H um phreys, G idm an & A ndrew s, 2000:311).Supporting students to learn in clinical settings is an im portant function for both ed u cato rs and practitioners, yet there is little consensus in the literature as to what constitutes appropriate support of clinical learning (Andrews & Roberts, 2003:474).The quality o f clinical learning o f students, according to A ndrew s & R oberts (2003:474) is influenced by a variety of factors including the learning culture and by more practical things such as how busy the area is and the level of patient need.Furtherm ore, the intensity o f support afforded to students is influenced by the nature and complexity o f the ward environm ent.M ore importantly, students view learning and p atien t care as tw o quite separate activities.Although clinical education is essential and valuable, it is not without difficulties and constraints as is stated by Tiwari, et al. (2005:299).To these authors, the clinical environm ent is unpredictable, constantly changing, and potentially confusing for students, hence promoting optimal learning in such an environment is challenging.M oeller (1984:205) also claims that the clinical instructor who supervises the student during the 'hands on' practice often bears the burden o f being the final gatekeeper to the profession.
The research conducted by Tiwari et al. (2005:299) revealed that stu d e n ts' learning during the clinical practice is, to a large extent, affected by th eir perceptions o f the assessment tasks.They learn for the examinations, not for the sake o f learning.As a result, they adopt a surface approach to learning and focus on preparing for the assessment of tasks to the detriment of their learning.These authors refer to this as a negative backwash effect on learning.These authors recommend research studies that will explore perceptions about student learning in the clinical environment and the relationship between assessment and student learning.This proposed research intends to describe the perceptions the pupil nursing auxiliaries have about their clinical learning, how they learn in the clinical settings, and the influence of assessment on their clinical learning.Mogan and Knox (1997:331), as well as Irby (2004:808), indicated that there are concerns about clinical teachers as role models in clinical settings.According to these authors, many clinical instructors and clinical staff fail to serve as exemplary role m odels in a num ber o f ways.H enderson (1995:121) view s role m odelling as a pow erful teach in g technique.According to Henderson, m odelling involves d em o n stratin g exemplary professional characteristics.T hese include the n o n -co g n itiv e dimensions of professional practice such as showing genuine concern for patients, recognizing o n e 's own lim itations, show ing respect for others, taking resp o n sib ility , and not ap p earin g arrogant.If the attending professionals treat patients with respect and genuine concern, students will do the same.The reverse is also true.Jinks and Paterman (1998:12) found that the students felt that they had insufficienient clinical skills upon com pletion o f p re -re g istra tio n programme.According to Bjork (1995:6), Elkan & Robinson, (1993:295), the production o f inadequately competent graduates is attrib u ted to ex istin g tension between education and service with regard to the value of practical skills in nursing.The priorities of these two (education and service) are not the same and the planning o f teach in g and learning is dom inated by education institutions with minimal involvement of service.According to Quinn (2000:417) qualified staff is a key factor in influencing the learning environment of student nurses during the clinical practice, the role of the unit m anager being particularly important.

Problem Statement
The study focused on bridging programme students because o f their dual status as students and employees.According to Zulu (2004:22) the learning needs of students of this nature are in most cases neglected, because they are regarded as part of the workforce.They do not get adequate clinical supervision because it is assumed they know most of the work.Some units rely on the bridging programme students because they are a better kind of student; they are familiar with the routine and therefore require less assistance and attention from the w'ard staff.Taking these students away from th eir daily activ ities for clinical supervision sessions poses a challenge because this means that the unit is minus a staff member.Work tends to be a priority as opposed to the learning needs o f students.L ita,A lberts, Van Dyk &Small(2002:30) found that the workload and shortage of personnel limited the opportunities for proper teaching and guiding of students.In a study o f perceptions of the clinical competences of newly registered nurses done by Moeti, Van Niekerk & Van Velden (2004:72) it was also found that a shortage of staff, equipment and supplies negatively affects the competency of students.Furthermore, when afforded an opportunity to attend a clinical su p ervision session together w ith traditional students, they are given less attention than the traditional students.It is assumed that bridging programme students are fam iliar with the ward procedures and most of what takes place in clinical settings.Ward staff tend to ignore that the bridging programme students are in the process o f being prepared for a higher level in their career and for responsibilities different from those o f an enrolled nurse.It is also acknowledged that some of the bridging programme students have, over the years o f their practice as enrolled nurses, developed unacceptable practices.They have to be assisted by clinical supervisors to relinquish these practices.A ccording to L ipinge and Venter (2003:10) negative experiences have also been reported by students in the clinical environment.This negative experience include for example (a) the expectations of students not being met, as the staff are not aware of the students' learning objectives (b) frustration experienced during daily practice due to poor integration of theory and practice and (c) the lack of tutorial support and guidance by lecturers.Interpersonal relationships between the w'ard sister and students are a problem.Students were called names and used as scapegoats for wrong doings.Because of these negative attitudes the students would have negative clinical learning experiences.Lack of effective communication between college tutors and ward s ta ff also contributed to negative experiences of students.
To identify and describe preconditions to be taken into consideration in a bridging programme for clinical supervision to be effective.2.
To identify the teaching/ learning processes during clinical supervision in a bridging programme.3.
To determine and describe the type of support provided to bridging programme students when they encounter a critical incident in the clinical setting.

Conceptual framework (Figure 1)
The conceptual framework is modified from the model which was developed by Hyrkas (2002:50).This conceptual fram ew ork has three im portant d im ensions; antecedent or preconditions, the core o f clinical supervision and outcomes of clinical supervision.Antecedent conditions are those conditions which should be in place before the actual supervision process.The concrete arrangements and reso u rces such as m oney, human resource, time and place are considered im portant preconditions for clinical supervision.Lack of resources seems to be the biggest threat to the occurrence o f clinical supervision.In the context of this study all resources for clinical supervision to take place should be provided.This will include appointing suitable qualified clinical supervisors, providing a set schedule ensuring that clinical supervision consistently takes p lace and to ensure that there is communication between the academic institution and the clinical settings.The contract between clinical supervisor and learner is the crux of clinical supervision.There should be an agreement between supervisor and student.The agreement is described as a contract where practical arrangements such as the duration of clinical supervision and the rules are discussed.The agreement should detail the roles, re sp o n sib ilitie s and expectations during the teaching learning process.The clinical environment should have appropriate learning experiences that will facilitate the development of required competences .Certain specific personal characteristics of the students are im portant for effective clinical supervision.This can be summarised in terms o f demographics, motivation to learn, self-confidence and willingness to acquire feedback.The core o f clinical supervision includes important issues such as clearly stated goals o f each clinical supervision session, a teachinglearning process that facilitates the achievement o f expected outcome, a relationship between the supervisor and the student that promotes learning, and availability of time for clinical supervision.The time aspect has been considered important in the sense that the time used for clin ical su p erv ision should be protected from other duties.The goals are describ ed as ind iv id u ally em phasised, based on the student's specific needs but also coherent with organization or unit activities (Hyrkas, 2002) .The teaching -learning process is described as having practice-oriented learning experiences com prised o f everyday learning.The supervisory relationship, especially the interaction between supervisor and supervisee, are seen as the core elements o f clinical supervision.The qualities related to the relationship and interaction have been described with several attributes such as supporting, facilitating and encouraging.Outcomes are related to development of the learner academically (knowledge, sk ills, valu es), p ro fessio n ally and personally.The b en efitin g re sto rativ e and supportive outcomes for an individual supervisee have been described in terms o f decreased stress, im proved self -confidence and a high self -esteem.

Research design and method
A quantitative and qualitative design was used in this study.Three colleges were used as research settings in this study (2 private and 1 public).These were the only three hospitals that offered the Bridging Programme.The researcher included students from the private institution because these students com e from d ifferent cultural race groups.The population was made up o f students enrolled in their second year in the Bridging programme.There is a chance that some of them may be supervised by a supervisor that is not from the same cultural groups.Second year students were thought to be more appropriate in this study because of the period they had already spent in the programme.The total population o f the three settings is 325 students.The target sample was 150 students.170 questionnaires were sent out to allow for attrition.The participants were randomly sampled and 122 returned th eir qu estio n n aires.O f the 122 participants in the study, 26.2% (n=32) were from College 1,15.6% (n= 19) were from College 2, and the majority, 58.2% (n=71) were from College 3. D ata was collected through a self developed instrument which was based on the Manchester Clinical Supervision Instrument by Winstanley and White (2002) According to W instanley and W hite(2002) the Manchester Clinical S upervision Instrum ent is the only in te rn a tio n a lly v alid ated research in stru m en t to m easure clin ical supervision.A critical incident was also used to gain more information about the support provided to students.The critical incident results were based on 25 participants.The low response to this critica l incident question was because it took longer to answer than the o th er q uestionnaire, and som e students said that the questions intruded upon the confidentiality of student and clinical supervisor.The p artic ip a n ts re flected on this situation, detailing the situation, the support system that was approached, the process by which the situation was dealt with, and the evaluation o f the support that was offered and recommendations for the future.Content validity was conducted by subjecting the instruments to the scrutiny o f experts in nursing ed u catio n and in research , and su ggested co rrectio n s w ere m ade ap p ro p riately .A te st-re te st was conducted to establish the reliability of the instrument.The questionnaire was administered to 10 students and then re administered after a two week interval.The answers were checked and to see that they w ere sim ilar on both the occasions.
Scores on the repeated testin g w ere com pared and the comparison was expressed by a Pearson r. correlation coefficient.The correlation yielded was 0.96, which supports the idea that the instrument has the attribute of stability.Permission to conduct the study was sought from the authorities and the participants completed consent forms after the process o f explaining the research and their rights.The names of the three colleges are not used as this was part o f the arrangement before data collection.The colleges are referred to as College 1, College 2, and College 3.

Data analysis
D ata w ill be q u alitativ ely and quantitatively analysed.Data was captured and analysed in SPSS version 11.5 (Chicago,111).phrased statements) and summed for each in d iv id u al, and to tal scores compared amongst the three hospitals using the sam e m ethods as above.Critical incidents and support given were categorized and compared amongst the three hospitals.

Results
The results are presented according to the major concepts in the conceptual framework that was used in this study; antecedent conditions, core o f clinical supervision and outcomes o f clinical supervision.

Antecedents of Clinical Supervision
Only

Clinical supervision antecedents
Although the respondents stated that there was no formal contract between them and the supervisor they indicated that the first session with the supervisor was used to detail the goals of clinical supervision, the roles and expectations from both parties (the student and the clinical supervisor).In this way there was a verbal co n tract.73% o f the respondents had a m eeting with the supervisor where what is supposed to be in a formal contract was discussed.22% had no formal session where roles did not respond to this statement o f the contract between student and supervisor.
The conceptual framework used in the study indicates that the availability and experiences is one of the preconditions for successful supervision and learning.56% (114) indicated that the goals of clinical supervision were stated, 31% (64) were informed of the role o f the clinical supervisor, 11% (25) knew about the role o f the students and 2% (5) had k n ow ledge o f the re la tio n sh ip betw een the su p erv iso r and the student (See Figure 3) .These areas should form part of the contract that is between the clinical supervisor and the student and the two parties should be inform ed o f the content o f the co n tra ct, as in d icated in the conceptual framework used in this study.
13% ( 16) o f the participants indicated that the clinical learning environment had adequate learning experiences while 80% (98) indicated that the experiences were not adequate.7% of the participants pointed out some learning experiences were irrelevant.
A ccording to the co n cep tu al fram ew ork used in this study inadequate and irrelevant learning exp erien ces lim it learn ers from develo p in g re q u ired clin ical competencies.
The conceptual framework used in this study indicates that the availability and adequacy o f clinical learning exp erien ces is one o f the preconditions for successful clinical supervision and learning.

Core of Clinical Supervision
About 61% (71) of the respondents indicated that clinical sessions took less that 15 minutes, 21 % (26) stated that the length o f their clinical learning sessions ranged between 15 to 30 minutes and 18% (22) had clinical learning sessions which were above 30 minutes (Figure 5).None o f the respondents had clinical supervision sessions daily.49% (60) had sessions weekly and 51% (62) had sessions fortnightly.96% o f the participants had a copy of learning objectives, and 3% reported that they did not have a copy.2% of the participants did not respond to this question.
Responding to the statement about the support in the unit, 66% (80) got support from peers, 32% (39) got support from the unit staff, and no participants had support from the hospital coordinator, 3% did not respond to this statement.
According to the graph (Figure 6) college 1 responses were significantly lower (tended to disagree m ore) than the responses from the other colleges in response to the statement that ward staff find clinical supervision time consuming.

Comparison of critical incidents between the three hospitals
The highest proportion o f incidents was reported in College 1, followed by College 2 and the lowest in College 3. Overall 21.2% (n=25) o f respondents reported critical incidents.O f the 25 participants who reported critical incidents, 68.2% receiv ed su p p o rt .T here was no difference in the proportion receiving support by h o sp ital.Thus sim ilar proportions of participants who reported incidents received support in the three hospitals.

Critical incidents
Critical incidences were also analysed qualitatively.Critical incidences are a set of procedures used for collecting direct observations o f human behaviour that have critical significance.A critical incident can be described as one that makes a significant contribution, either p o sitiv e ly or n eg ativ ely , (h ttp :// w ik ip ed ia.o rg /w ik i/critical incident technique 16/09/08) Two them es, academ ic support and emotional support emerged out o f the critical incidents.

Academic support
One student reported that the ward was grossly short staffed and that she was allocated to care for a patient with a tracheotomy.This task was allocated to her because it was assumed that as an old stud en t, she w ould have been exposed to such a pro ced u re, but, unfortunately for her, it was her first time.The student felt uncomfortable reporting this to the unit manager, but the unit manager noticed that this student had a problem, and made time available to teach the student.The unit manager was very supportive.She demonstrated to me the procedure, startin g from the settin g o f the tracheotomy tray, to the procedure of caring for a tracheotomy.
According to Lyth(2000) the supportive and restorative outcome o f clinical have been decreased anxiety and decreased stress.Some o f the p a rtic ip a n ts how ever rep o rted th at they did not receive academic support because they were regarded as a burden by the unit staff.Sometimes the unit were grossly short staffed and they w ere expected to function independently even when they required some guidance.The unit staffs' attitu d e tow ards them w hen they requested to be taught something was very negative.They were regarded as old nurses with experience, neglecting the fact that they were being trained or prepared to be a different category of nurse (registered nurse).They had never functioned as registered nurses before.Whatever they had learned was mainly in service as enrolled nurses.Sometimes we were highly stressed to complete our tasks before the end of the year.We were overworked and not given enough time to learn.As a result we found ourselves behind com pared to other students.According to Morton Cooper Palmer (2000) the role o f the supervisor is describ ed as su p p o rtiv e in accom plishing a task, assessing and solving work related problems with the student and assessing the skills and knowledge of individual students.The participants reported that they were treated differently as opposed to four year com prehensive students.These nurses received more support than they did.Time was made available for such students to attend teaching sessions, whereas in most cases it was assumed that old students knew most of what was taught in the ward and therefore should continue with their work.They were not given an opportunity to choose whether to attend the sessions or not.Sometimes, due to staff shortages, they were used as part o f the workforce because o f their experience, bypassing the reason for their presence in the units, namely to learn what would be expected from them as registered nurses..One of the participants reported that being regarded as part of the workforce delayed her in completing her objectives in particular units.I wanted to attend a demonstration as was expected according to my workbook, but the sister who was leading our team just said no, because there was no one to continue with my tasks.She did, however, allow the four-year course student to attend.

Emotional support
Some of the participants, although only a few, poin ted out th at in critica l incidences they did receive some form of support.There were times where the unit staff ensured that they received support even from other professionals.One o f the participants reported the death of a baby due to the unavailability o f doctors in private institutions.The student blamed herself for not doing enough.The student received support from the ward staff and was sent for counselling

I was blam ing m yself because we lost a baby in the unit. I was the only one in the unit. The sister and other sta ff members were on a tea break and the other staff member was busy with the errands. The c ritic a lly ill ch ild su d d en ly tu rn ed blue an d re q u ire d re su sc ita tio n . The d o c to r w a s not available. In private hospitals, getting a doctor fo r resuscitation takes time, and there was no readily available team fo r resuscitation. I called fo r help, but the response was poor and we lost that baby. I could not take what happened, but the w a rd s ta ff w ent out o f th eir w ay to support and counsel me. I was even referred to the psychologist fo r help.
According to White et al (1998) outcomes such as professional support and gaining support for work related problems are developed during clinical supervision.Some o f the p artic ip a n ts receiv ed em otional support especially when dealing with difficult patients.It emerged from the findings that some of the patients undermined students and only respected qualified nurses.About three o f the participants reported that they were physically assaulted by patients who undermined them, but who changed their behaviour when the qualified nurses attended to them .In tw o o f these incidences the unit staff supported the students and intervened.One o f the participants was bitten by a patient on the arm.She was counselled and the procedure o f needle stick injury was followed and she was started on Antiretro-viral drugs.In one of the incidences, it was as if the student invited the assault.Instead o f being supported, she was m ade to com plete a statem en t independently with no one guiding her through the process.She was humiliated by the patients in front of the patients and unit staff, and was also humiliated by the unit manager who shouted at her in front of all these people and ordered her to write a statem ent, instead o f atten d in g to her as she h ad been assaulted by the patient:

I once worked in a unit where a sister was not sym pathetic to our needs as students. I was pregnant and I started to b le e d w h ile I w as a t w ork. When reporting my problem to the sister she ignored me instead o f allowing me to go and seek medical assistance. I was made to continue with my work. After some tim e I d ecid ed to phone m y clin ical instructor and report to her because the problem was getting worse. She then
intervened, an d that is when / w as allowed to attend to my problem.White et al (1998) emphasises that clinical supervision is a form of employee mental health care or preventative mental health welfare and a part of occupational safety.From the participants' critical incidences it also became evident that the emotional support they received was very limited, especially from the unit managers.They were mainly expected to work, even when they had social or health problems.The unit m an ag e rs' concerns w ere the coverage of the ward hospitals.

Discussion of Findings
The m ajority o f the respondents acknow ledged the need for clinical supervision.The students found clinical supervision useful in promoting working p ractices and in fa cilita tin g their professional development.It is difficult to establish supervision w ithout the d ed icated support o f the clin ical supervisor.It takes great energy to keep the groups focused and committed in an environment where there are continuous high patient workloads and frequent shortages of staff.

Preconditions or Antecedents for clinical supervision
The findings in this study revealed that other institutions lacked trained staff to carry out supervision.They used clinical supervisors without a nursing education qualification which is not in line with the South A frican N ursing C o u n c il's expectations.Lack of trained staff was one o f the d ifficu lties o f clin ical supervision which was pointed out by Thomas and Reid (1995:883-885).It em erged in this study that the time available was insufficient for clinical supervision, and the opportunities for reflection were limited due to busy wards.Some of the clinical staff was not in favour of releasing students to attend clinical supervision sessions because students served as an extra pair of hands.The bridging programme students were still regarded as part o f the unit staff, and releasing them for clinical supervision sessions m eant that some activities would not be performed.The findings revealed that there was a large age gap between the clinical supervisors and the students and that all clinical supervisors were females..It was not easy to establish why certain institutions used unqualified nurses, but according to Thomas and Reid (1995p883-885) untrained staff in their study was used as a result of a lack o f trained staff.The researcher was unable to establish from participants whether those who possessed a nursing education qualification were prepared academically for this role.This answer would have been answered if nurse educators were included in this study.From the researcher's experience, the train in g and education o f nurse educators does not go in-depth with clinical supervision.Only the basics of clinical supervision are discussed.

Core of clinical supervision
The first session of clinical supervision was used to explain the goals of clinical supervisions, the expectations, roles and responsibilities o f each party (clinical supervisor and student).The participants reported that they had individual as well as group clinical supervision sessions, and most o f the p artic ip a n ts, (71% ) reported that sessions lasted less than 15 minutes.R elatively few p artic ip a n ts (29% ) received clinical supervision that was longer than 30 minutes.This suggests that less time was allocated to clinical supervision.According to the framework which was used in this study adequate time should be allocated to clinical supervision sessions, because clinical supervision facilitates the development o f studen ts as professionals.The participants pointed out that more time should be dedicated to clinical teaching and learning, they should have more frequent sessions, and should not be regarded as part of the workforce but as students first, then secondly as part of the clinical staff.This supports the findings in the study by Winstanley and Edward (2003:6) that longer sessions and more frequent sessions may be more effective.The findings showed that most ward staff in the three hospitals found it difficult to find time for clinical supervision sessions as it was tim e consum ing.This is supported by D avhana-M aselesesle (2000:126) in her study on problems with in teg ra tin g theory and p ractice in selected clinical nursing situations that due to the lack of time and knowledge of p ractical sk ills as w ell as lack o f confidence, tutors and ward staff are not fully involved in clinical supervision.

Outcomes of clinical supervision
The purpose o f clinical supervision emerged as being to promote academic, personal and professional growth in the students.A lthough this was not supported in some units, there were units which supported this aim.This was in line with the developmental model which was described by Leddick (1994:10-24) as having three developmental phases w ith the student m oving tow ards com petence, self-assurance and self reliance.To facilitate growth, each student had a copy o f objectives to be covered in the clinical settings, but the participants raised the concern that they were unable to cover all the objectives on time because they were overloaded with work in the units, and were not regarded as students.They did not have enough tim e to develop them selves towards becoming professional nurses.They were still treated as staff nurses who were part of the work team.
The form ative aspect (educative) o f clin ical supervision was m ore pronounced compared to restorative and normative aspects.According to the findings in th is study, clin ical supervisors focused more on facilitating the developm ent o f technical skills instead of facilitating the development o f competencies (knowledge, attitude and skills), and the ability to reflect.The aspect of promoting guided reflection did not come out clearly in this study.
It was found that most ward staff and students becom e m otivated during clinical supervision sessions, despite the fact that the clinical supervisor may discuss sensitive issues that have been encountered during clinical supervision sessions.The critical incident analysis revealed that supervised nurses continued to use inform al support as w ell as th eir supervision sessions to discuss clinical issues.How clinical supervision emerged in this study was in line with how Winstanley and Edward (2003:3) view clinical supervision.These authors however also add that clinical supervision enables individuals to develop competence and assume responsibility for their own p ractice and to enhance consum er p ro tectio n and safety in com plex situation.E nhancing patient safety em erged when p a rtic ip a n ts were reflecting on critical incidences.In some situations where participants were not skilled, or not familiar with a procedure to be performed, the clinical staff made them selves a v a ila b le to help the participants and to protect the patients.

Recommendations
Recommendations will be discussed under three h ead in g s, nam ely Preconditions or Antecedents for Clinical Supervision, Teaching Learning Process and Support.Teaching Learning Process

Preconditions or Antecedent
. d ecreased stress, im po confidence, high self-esteem Frequency distributions were used to analyse the Section A(demographic data, and Clinical Supervision antecedents) and Post hoc Kruskal-Wallis Multiple Comparison Z value tests were performed in NCSS (Hintze, J. 2001) to analyse section B (clinical Supervision Scale) Since the dependant variable was significantly non -normally distributed, a non -parametric equivalent o f one-way ANOVA (ie, the Kruskal-Wallis test) was used to compare values between the groups.If the overall test was statistically significant, post hoc z tests with a Bonferroni adjustment were used to determine which groups were indeed statistically significantly different from each other.The questionnaire contained 42 individual statements on clinical supervision.These were graded on a L ik ert scale, and treated quantitatively.The distribution of these responses was highly skewed, thus nonparam etric m ethods w ere used for d esc rip tio n and analysis o f the statements.Comparison of the responses to the clinical supervision statements amongst the three colleges was achieved by nonparametric Kruskal-Wallis testing, with post-hoc Multiple Comparison Z value tests.Responses were scored (scoring was reversed for the negatively

Figure
Figure 2: Ages of students versus the ages of clinical supervisors

FigureFigure 6 .
Figure 3. Contract between Students and Clinical Supervisor

Operational Definition of Terms C lin ical su pervision is a process 48 Curationis December 2008
Bridging programme refers to a tw o year Diploma in G eneral Nursing (often referred to as the bridging programme) leading to registration as a general or psychiatric nurse in accordance with the SANC Regulation No. R683 of April 14, 1989 as amended.

2000: The nature and purpose o f the role o f the nurse lecturer in practice settings. Nurse Education Today, 20, pp311-317. HYRKAS, K 2002:
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