Paul Morrison, Murdoch University, Australia
The need to provide support for practising health professionals has been generally recognised and one of the most commonly employed approaches is clinical supervision (Milne, 2009). The process of clinical supervision is complex and has a long history in the helping professions (Grauel, 2002; White & Winstanley, 2014) and forms the basis for professional development and competent ethical practice (American Psychological Associate, 2015; Milne, 2009). The potential benefits of clinical supervision in nursing and other disciplines have been widely advocated (Campbell, 2006; McMahon & Patten 2002; Snowdon, Hau, Leggat, & Taylor, 2016). The absence of a precise definition of clinical supervision has not curtailed the growing interest in this process (White, 2016; White & Winstanley, 2009). Referring specifically to the field of mental health practice Campbell (2006) noted that:
“primary purpose of clinical supervision is to review practitioners’ work to increase their skills and help them to solve problems in order to provide clients the optimal quality of service possible and prevent any harm from occurring. Therefore it is a teaching and training role as well as a monitoring function” (p. 2).
In the clinical nursing context, several papers have identified positive outcomes of clinical supervision. Bégat & Severinsson (2006) found that nurses who were engaged in clinical nursing supervision were more satisfied with the psychosocial elements of the work setting. Crowther & Jeffrey (2007) described a group reflective program to develop mental health nursing services which led to a reduction in “the level of anxiety and uncertainty surrounding the nature of clinical supervision and… a demonstrated willingness to work collaboratively towards the introduction of a formal process of clinical supervision” (p. 27). In a review of the literature on clinical supervision, Butterworth, Bell, Jackson and Pajnkihar (2008) observed that clinical supervision was seen as a health care organisational responsibility and showed some potential for enhanced patient outcomes.
It has been suggested that clinical supervision can help to keep the effects of job stress in check while helping to motivate and enhance peoples’ commitment to their work (White & Winstanley, 2010). The Australian College of Mental Health Nurses (2011) has endorsed the process for all mental health nurses, while Lynch, Hancox, Happell and Parker (2008) make the point that clinical supervision should be a key facet of professional nursing practice. White (2016) however, offers a more cautious note, arguing that the evidence supporting the efficacy of clinical supervision is rather thin.
While the commitment to ongoing supervision appears to be gaining ground in clinical settings the induction process for new academics tends to be limited (Staniforth & Harland, 2006). This contrast is especially important for nurses who move from a nursing practice environment to an academic one.
Universities are very competitive places to work (Kennelly & McCormack, 2014). In highlighting some of the difficulties new academics face in a culture that focuses on the individual, Tynan & Garbett (2007) advocate for a truly collaborative mutually supportive approach to scholarly work. The assessment offered by Remmik & Karm (2012) was rather stark: “Novice teachers often find that they are left to ‘sink or swim’ in front of the students” (p. 122). Such an environment is unlikely to foster a culture of collegiality (Nagy & Burch, 2009).
The need for appropriate mentoring schemes to develop academic staff in nursing (Potter & Tolson, 2014), medical (DeCastro, Sambuco, Ubel, Stewart, & Jagsi, 2013) and other areas (Kensington-Miller, 2014) is well recognized. Mentoring and other supports may be needed to help staff make a successful career path change. McArthur-Rouse (2008) described the transition into the university from the world of practice as a move from “expert to novice” (p. 401). Teaching skills do not occur spontaneously and both new and experienced staff have development needs (Foley et al., 2003). It is not always true that a skilful clinician will be a skilful teacher and, while expertise in the subject matter is important, proficiency in facilitating learning is equally, if not more, important (Siler & Kleiner, 2001). Many universities provide short courses in teaching for new staff to help with the transition. However, these courses may be insufficient and further training or support may be required to enable new staff to successfully adapt to academic work (Boyd, 2010; Danna, Schaubhut, & Jones, 2010; McArthur-Rouse, 2008).
Peer review is one way to develop as a teacher and has the potential to be a constructive source of learning for those involved. However the academic culture is very competitive and many academics may feel uncomfortable with peer review as it can elicit strong emotions and fears about being scrutinised and undermined (Brookfield, 1995). Being evaluated by peers may lead some lecturers to respond defensively, even to constructive criticism. Such a stance however means that helpful feedback may go unheard.
In exploring a collegial mentoring model for nurse educators, Thorpe & Kalischuk (2003) emphasised the need to provide ample time to establish and nurture positive relationships, and reflect on teaching practice. Colleagues were drawn to the practice of outsider witnesses in narrative work (White, 2007). This approach appealed to the group as stories are very much part of the nursing culture perhaps because: “Stories remind us of what it means to be human in all our complexity, differences and diversity” (Killick & Frude, 2009, p. 853).
This paper builds on literature detailing academic support through providing a personal account of how narrative therapy (White & Epston, 1990) can be used to support the transition through university culture. As I was familiar with narrative training and practices of helping, the group chose this approach rather than use other models of mentoring and team building (see for example DeCastro et al., 2013; Kashiwagi, Varkey, & Cook, 2013; Kensington-Miller, 2014; Potter & Tolson, 2014).
The sessions described here draw on reflecting teams and outsider witnesses from the field of therapy and narrative therapy (see Morgan, 2000; Freedman & Combs, 1996). In therapy a reflecting team might involve a number of professionals or trainees who observe a therapeutic interaction from behind a glass window and comment in a speculative manner (see Andersen, 1991; 1987). Using the structure of the reflecting team (Andersen, 1991) and Myerhoff’s (1986) “definitional ceremony” (p. 267), White (1995) developed the idea of outsider witness practice as a means of helping people see and bear witness to their own worth and identities.
An audience (of outsider witnesses) is invited to listen and reflect on clients’ stories as the client developed new and rich stories about themselves and their preferred ways of living. The role of the audience (typically a family or other people important to the client) is to help the person to ‘make space for an alternative story to emerge’ (Roberts, 2000, p. 437).
Importantly members of the outsider-witness team do not provide ‘expert’ commentary. The audience of outsider witnesses avoid making interpretations, offering advice or praising peoples’ achievements (Payne, 2006). Their main aim is to accept the validity of the person’s problems and conflicts and by so doing “provoke people’s fascination with certain of the more neglected aspects of their lives” (White, 1995, p. 180). The outsider witness team does not provide an evaluation or constructive critique unlike what might be expected in a peer review. The role of therapist or facilitator is critical here, they provide the scaffolding to ensure the outsider witnesses keep on track.
The outsider-witness process is a practice of ‘acknowledgment’ in which some aspects of a person’s story ‘resonate’ with the audience (White, 2004). Resonance is fostered by teasing out from the participants who witnessed the story: (1) the specific expressions or images raised; (2) aspects of identity elicited by these expressions; (3) how these touched the participants and (4) how the outsider witness team participants’ lives were changed as a result. The use of outsider-witness practices has been used in a range of ways with women who have experienced child sexual abuse (Fraser, 2006), in a prison setting (Smith & Gibson, 2006), and in learning about mental illness (Morrison, 2009, 2010). Fox, Tench, & Marie (2003) used the outside witness approach in a supervision setting.
The teaching team within an Australian School of Nursing was a relatively new group with varying degrees of experience. The group was established at the request of several members of the teaching team. As an experienced academic (nurse and psychologist) with additional training in narrative therapy I was asked to facilitate the sessions. A small number of accessible readings were made available to staff beforehand. Of the staff available to attend these group meetings, only five were regular attendees across a six month time period. The group meetings were structured so that one participant was invited to share a story about their work and the facilitator would ask a range of questions such as those in Table 1 over a 40-minute period.
Table 1: Sample questions for the interviewee
1. |
Can you tell me a story about some aspect of your teaching? |
2. |
What did you appreciate or value about your work at that time? |
3. |
Why is this important to you? |
4. |
Imagine a year from now and your work is grounded in the things that are important to you, how would you know this to be the case? |
5. |
What steps could you take to move in this direction at work? |
6. |
What resources might be needed? |
The other participants were witnesses to the story that emerged. The facilitator then asked the members of the outsider witness group questions about what they had witnessed. The questions were adapted from Stringer et al (2003) (see Table 2). This was followed up with some more questions for the person interviewed initially and some general conversation around the issues and process.
Table 2: Questions for the outsider witness group
1. |
As you listened to (name)’s story about their work which particular images or expressions caught your attention or struck a chord for you? |
2. |
What did these images or words suggest to you about (name)’s work and life? |
3. |
What is it about your own life and work that explains why these images caught your attention? |
4. |
Where has the experience of hearing this story taken you? What will you take with you into the future? |
After six supervision sessions, participants’ perceptions of the meeting process (including my own) were explored. The final account described below is based on notes, recollections and personal reflections I made during and sometimes after the sessions ended. It is acknowledged that my experience and views about narrative practices may have unduly influenced the general positive tenor of the description below. However, the reader can decide if these ideas warrant further consideration. The review is arranged in a question format in keeping with the general character of outsider witness practices and the responses to these are essentially a personal distillation.
Participants emphasised the atmosphere of trust and openness and how that fostered learning. The sessions built collegiality and mutual support and there was a willingness to engage constructively with the process. The potential application of the outsider witness approach beyond the therapy room was acknowledged. The process also appealed to participants with different learning styles.
Participants learned that the space created allowed for self-reflection and personal change. They learned how to stay in the moment and ‘be with’ another person through reflecting on colleagues’ experiences of teaching and associated feelings. They learned about the importance of resonance, connecting their lives with others through stories.
A number of important things were highlighted here. Participants identified the need to check students’ understanding of material and not to assume they understand. They acknowledged the difficulty of trying to know everything or reach every student while they acknowledged that teaching can be motivating for lecturers and students. Participants noted that guided conversations are more fruitful than telling students what to do. They also stressed the need to create a safe space for exploring teaching practices in the future and that real collegiality can lead to developments in teaching practice.
The sessions helped participants to recognise the value of sharing concerns about teaching and university work and to aspire to collaborative, supportive and facilitative ways of working with colleagues. This resulted in a more balanced, less critical approach to performance review, and allowed fears to be explored in an empowering manner without the fear of criticism. They discovered the power of personal resonance with the lives of others and recognised the value of questions guided by narrative practices.
Participants felt that the approach mirrors and enhances the self-reflecting development work of clinicians and students. It evokes an environment of high challenge and high support and instils confidence to take some considered risks in teaching practice. The approach could be employed consistently to develop the practice of other nurse academics.
Some participants felt that placing a greater emphasis on the safe and confidential nature of the process would make it more appealing to others. At the same time it was important to affirm that invited participants always have a choice to engage or not. It was also important to acknowledge the risk of adopting this approach without skilled facilitation and sound knowledge of narrative methods. As with anything new or different there may be a temptation for it to be misrepresented as something that only a few can do making it an exclusive rather than an inclusive process.
The review and reflection described above is very much a personal one – a personal distillation as a facilitator/participant in the outsider witness informed support meetings. In that personal account I tried to capture some of the experiential elements that were elicited during the sessions. In the next section I will attempt to locate these within a more scholarly context so that the significance of the outsider witness approach may be better understood and its potential in helping to provide support for academic nursing staff better appreciated.
The outsider witness approach is a rather unusual and engaging one and as a result this encouraged participants to think and interact differently. Arguably all human experience and knowledge is, or can be, storied and explored and personal meaning can be constructed around these stories (McAdams, 2012). The level of engagement of participants as the storyteller or outsider witnesses through establishing a personal resonance with and acknowledgment of other participants’ stories was powerful.
The sessions also allowed opportunities for the participants to reflect on their experiences and develop new insights into their teaching and other facets of academic work. Freedman and Combs (1996) noted how reflection helps to “embody particular attitudes and postures” (p. 177). This reflective process enabled some participants to begin working with students and colleagues in different and more valued ways. The process led to a personal engagement with ideas that could enhance their work with students.
The structure helped staff to work together.
The process helped to develop a greater sense of connection by learning through others’ experience and reflection, which also reduced feelings of isolation. Moreover the process fostered the development of new perspectives on work and the growth of new and more trusting relationships with colleagues. It is possible that when people engage in outsider witness groups they experience a strong sense of being connected to other people through shared experiences, intentions and hopes (Thorpe & Kalischuk, 2003). The approach promotes the space to talk about feelings and experiences within an atmosphere of authenticity, honesty and collegiality.
The process helped to create a place of safety in a very competitive academic environment. This provided participants with a strong sense of acknowledgement of their work and the values that underpin this work. At the same time it evoked conversations about the real challenges presented by the university environment such as the demands for excellent teaching, quality research and clinical credibility and the ambiguous roles these entail.
Stilos and Moura (2007) highlighted the importance of dealing with ambiguity as an essential requirement for change: “The wonderful thing about ambiguity is that it relieves nurses of the obligation to know everything” (p. 262). This adjustment in emphasis from the expert who knows everything is very much in keeping with the more realistic role of helping the client or patient or the student to assume more responsibility for their choices and decisions. Adopting a more realistic perspective on the demands of the workplace provides a sound foundation for dealing with on-going change. In a similar vein, Wilson and Ferch (2005) argued that resilience can be fostered in organisations through caring relationships that help people to interact in ways which promote personal development.
Motivation for learning summoned from the participants’ work or life frequently leads to strong engagement and learning (Ramsden, 1992). The outsider witness sessions were especially salient to the work of the participants because the stories were about real teaching and learning experiences. The learning that occurred also focused on changing how participants engaged with some routine aspects of daily work such as the importance of staying in the moment, acknowledging others’ experience and feelings, and checking for understanding following lectures and tutorials.
Moreover the process helped participants to share concerns and explore fears through guided questionings that did not diminish, judge or evaluate but which helped to acknowledge and affirm personal goals, hopes and values in their work. In some ways the sessions provided a form of support that is often lacking or haphazard in a university context. Remmik, Karm, Haamer and Liina (2011) noted that:
“novice lecturers find support through informal relationships within the workplace community. Therefore the support is often random and depends on the nature of these relationships as well as the novice lecturer’s own readiness to ask for help. Opportunities to learn in the workplace also depend heavily on the traditions and activity of a particular unit” (p. 196).
Collegial relationships also play an important role in learning within an organisation and the outsider witness process helped participants to share aspirations, concerns and practical advice about work. This shared understanding helped to develop enhanced working relationships. Wenger (1998) makes the point that learning is essentially a ‘social phenomenon’ that mirrors our social nature and desire for human interaction found in most community settings.
Learning is always about personal change and development and the narrative approach used showed some possibilities for change in the way participants thought about themselves, their roles and their values at work. Rossiter and Clark (2007) argued that narrative plays a crucial role in adult education generally while Goodson and Gill (2011) claim that:
“narrative encounter has the potential to transform a person’s understanding of him/herself, their narratives, and above all, to change a person’s courses of action and align them to the individual’s values and purposes in life” (p. xiv-xv).
Similarly, in an illustrative account of how psychological meaning can be distilled from narrative transcripts, McAdams (2012) described how the storytellers in his studies (American adult informants) identified a turning point in their life narratives and referred to these as “redemptive moves” that can “give people the confidence and psychological resources needed to soldier on…” (p. 25). In the competitive culture that characterises university settings today, the application of narrative informed approaches to work might help to bring forth more supportive structures at a local level and assist academic staff to address some of the challenges more effectively.
In a somewhat stinging critique of the dominant model of education in clinical psychology, Bradley (2009) highlighted the crucial nature of experience in professional practice. He argued that in spite of the fact that experience forms the basis of sound clinical judgement; the status of experience has been diminished in education. The same could be said for all helping professions where evidence based interventions are privileged above all else. Indeed, the need to demonstrate how evidence is integrated into professional degree teaching programs at university is often highlighted in the accreditation standards of professional bodies. In this context, the support sessions offered an opportunity to acknowledge and explore participants’ experiences of teaching at university and to place these experiences at the centre of their work alongside the organisational priorities of evidence based content, increasing student numbers, sustainability, and research performance. These personal experiences (along with their potential for learning) can be lost in the general clamour of work.
With any new approach or idea that is different there is a danger that it appears very helpful to participants when compared with what is known and familiar. Care needs to be taken to evaluate this approach (and others) rigorously. In addition to the facilitation skills needed (Heron, 1999), there is a need for considerable support from the narrative therapy literature (White, 2007) to ensure that the process accords with narrative values. The approach is not merely a set of questions or a simple format; it embraces a set of beliefs and values about people and helping. More general considerations when setting up reflective groups should also be explored (Paley, 2012).
Howard (2008) proposed that we move beyond the traditional use of clinical supervision as a way of promoting self-care and managing stress at work to instead embrace the process as one that may be employed to promote wellbeing. She advocated for the use of ideas from the positive psychology literature while highlighting the potential for a narrative approach. There are many different ways to explore supervision in an academic setting that may help to address the very competitive and lonely environments that can all too often develop. For those keen to explore the narrative approach, Payne (2006) provides a structure for organising supervision sessions that could be adapted to suit a range of circumstances. Whatever approach is employed it is imperative that universities seek ways to support the development of academic staff and help them contribute to the growth of a faculty learning community where participants feel safe, trusted and supported (Matthew-Maich et al., 2007).