Clinical supervision for nurses in the HIV sector

Judith Gorst: Prahran Market Clinic, Victoria

Introduction

Clinical supervision is not the norm for people working in nursing, though it is well established in mental health nursing.[1] There is a general assumption that nurses and doctors have the capacity to push on through, regardless of what they may endure at work. This notion may have developed because health workers’ traditional working environment has been in acute settings with a constant flow of patients. Hence this is the first, formative environment to which all health-care professionals are exposed. The provision of a time and space to discuss, reflect and question the care being provided and the personal impact of the work may seem unrealistic and are certainly not part of the cultural norm. Health-care professionals frequently conduct conversations about patient management but the nature of these discussions tends to be linear, direct and solution-focused, not reflective.

What is clinical supervision for?

The Australian Clinical Supervision Association (ACSA) defines supervision as:

‘A formal professional relationship between two or more people in designated roles, which facilitates reflective practice, explores ethical issues, and develops skills.’[2] The ACSA emphasises that it is not based on a hierarchical relationship or culture, and that the power lies with the supervisee.

The chief purpose of clinical supervision is to provide a space for the supervisees to discuss and reflect on the nursing work they are doing with their clients. This can take place one on one or in a group setting. Trust and confidentiality are essential components of good supervision.

Ideally, a qualified, external supervisor, with specific knowledge of the human immunodeficiency virus (HIV) sector, who is not the nurse’s line manager, is best positioned to provide clinical supervision. Supervision is not about performance appraisal. Good supervision allows for a discussion to unfold and grow and for themes to develop. It allows the supervisees to expand their understanding of their clients’ condition and life situation. It also provides an opportunity for the supervisees to reflect on their own strengths, deficits and needs, to examine their practice and the rationale for their approach, promoting professional growth and therapeutic awareness.[3] Of equal importance is the space it provides for a conversation to develop about the emotional impact of the work. Supervision provides a forum for the supervisees to talk about the toll the work might be taking on them as clinicians, and identify strategies to deal with this situation.   One of the roles of the supervisor is to provide support as well as a critical and positive endorsement of the supervisee’s work.

The supervisor maintains a clear boundary between the supervisee and the employer and will only report any concerns to the employer if he or she sense that the supervisee is at risk, or is placing clients at risk.

Why should nurses working in the HIV sector to be provided with clinical supervision as a routine part of their role?

There are a variety of reasons why clinical supervision is relevant for nurses caring for people with HIV. Since HIV has become a chronic condition rather than a life-threatening, terminal illness there is now a far greater emphasis on care in the community. Working in the community or general practice requires the nurse to work more autonomously than in the acute sector. This is an attractive aspect of the job for many nurses. However, it potentially poses challenges which warrant the provision of supervision on account of the complexity of the clients’ health issues, and the resultant risks to which the supervisee, the clients and the employer may be exposed.

There are numerous potential risks. Apart from compassion fatigue and vicarious trauma associated with working with complex clients who are unwell, nurses may also find themselves in a position which is outside their knowledge level or scope of practice. For example, they may be asked by their client for advice on an ethical dilemma around the disclosure of blood-borne virus status or safer sexual or injecting practices. It is, at the best of times, difficult to answer queries of this sort briefly, without the opportunity to explore the context and reason behind the question.  In the context of a nursing appointment, this is even harder. Providing a response that is either inaccurate or that may be interpreted as discriminatory and stigmatising is a risk. By providing misinformation in this situation the client (and others) may, inadvertently, be harmed. There is also a risk that the organisation may be held responsible in some way for the information offered and that its reputation might thus be affected.

People with HIV who need nursing care often present the nurse with an enormous range of clinical, psychosocial, cultural, social and ethical challenges. The clients in this group, whether they are being cared for in a community or hospital setting, are often extremely unwell and present with more than one clinical issue. The nurse is often required to use skills more often used by social workers, community, alcohol and other drug workers, mental health practitioners and pastoral care workers. Social workers and health-care workers in the mental health and drug and alcohol sectors are not only routinely provided with clinical supervision, they are expected to access it as part of their registration with their professional bodies.

Clinical supervision holds a mirror up to the work that the supervisee is doing with clients. As the supervisory relationship strengthens and develops it allows the supervisee a space to discuss issues or clinical presentations that may be troubling or unsettling for them. The impact of working with this client group can and does cause compassion fatigue and burnout. Clinical supervision is not only a safety net but should be an essential part of a nurse’s professional development and self-care.

Resources:

Australian Clinical Supervision Association
http://clinicalsupervision.org.au/

1.
Australian College of Mental Health Nurses. Clinical Supervision Position Statement. 2011; Canberra, December. 
2.
ACSA. Clinical Supervision: A Working Definition. ACSA Definitions Report. Forest Lake, Qld, 2014. 
3.
Australian College of Mental Health Nurses. Clinical Supervision Position Statement. 2011; Canberra, December.