Viewing Rehabilitation Nursing Like a'Magic Eye' Picture: Clinical SupervisionCan Sharpen the Focus

Christine Anderson, BAA(N) RNJan Park Dorsay, MN RN

This article discusses the contri­butions ofrehabilitationnurses to theinterdisciplinary team process. Theauthors propose that the process ofclinical supervision can help nursesexamine client interactions in newways, thereby enhancing their in­volvement in the interdisciplinaryteam process. An analogy to a "mag­ic eye" picture is used to encouragenurses to examine the importance oftheir role within the interdisciplinaryteam.

Address correspondence to Chris­tine Anderson, 1200 Main StreetWest, Hamilton, ON, Canada, LBN3Z5.

Nursing contributions to interdisciplinary team case conferences have been describedas inconsistent (Busby & Gilchrist, 1992; Warner, 1993). To achieve coordinated, co­operative, and goal-directed teamwork, all team members must be comfortable with theirinput and contributions (O'Toole, 1992). Nurses' limited and inconsistent contributionsto interdisciplinary team case conferences may be the result of either a lack of clarityabout their role or the absence of a structured framework for reporting. Opportunities toimprove rehabilitation nursing practice might become clearer if the nurse's role is viewedin the same way that a "magic eye" picture is viewed. In a magic eye picture, close scruti­ny is required to gain a perspective of the smaller picture that exists within the largerpicture. Similarly, it is only through a close examination of the role of the nurse withinan interdisciplinary team that nurses will gain clarity about their role. Once their rolebecomes clear, the larger "magic picture" incorporating all members of the care teamcan be better appreciated. Clinical supervision is one process that can be used to sharp­en the focus of this picture within a picture.

The big picture: The interdisciplinary rehabilitation teamInterdisciplinary team functioning has been described as a process in which staff pro­

vide coordinated services aimed at achieving established client goals (Jaffe & Walsh,1993). Rehabilitation seeks to treat the whole person who is experiencing impairmentsin physical, psychological, social, and vocational functioning. The need to coordinatethe activities of a wide variety of rehabilitation professionals is central to the concept ofinterdisciplinary team functioning. Strasser, Falconer, and Martino-Saltzmann (1994)reported that interprofessional relations and professional boundary blurring contributeto discord within rehabilitation teams. Team members, believing that their input is notvalued by others, characteristically demonstrate defensiveness about their own roles.Rothberg (1981) stated that the team approach requires tolerance for role ambiguity.

Interdisciplinary teams involve members who may be involved in problem-solvingactivities beyond the scope of their own knowledge base. To solve problems, interdis­ciplinary teams require the combined knowledge base of all of their members. The ef­ficacy of the interdisciplinary rehabilitation team depends upon the quality of the pro­ductive working relationships among team members. Team participants must be willingto assist and collaborate with each other. Joint decisions are based on relevant and ap­propriate input from all team members. It is crucial that all participants feel that theiropinions are being considered and their input is valued. The most common barriers to ef­fective team functioning are self-serving attitudes and territorial behaviors (Ragnarsson& Gordon, 1992).

Most healthcare professionals become team members as a result of the circumstancesof their jobs, rather than as a result of formal education (Diller, 1990). Benson and Duca­nis (1995) said that both success and problems in team functioning can be traced to theissue of clarity of professional roles within the interdisciplinary team. When profes­sionals from various disciplines work together on a common problem, it is normal to

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find that they have differences regarding role expectations. Un­clear expectations about responsibility and an absence ofan un­derstanding of appropriate roles can result in team conflict. Eachprofession brings a different set of values to an interdiscipli­nary team. Team members tend to identify, first, with their pro­fessional discipline, and only second, with the interdisciplinaryteam's goals (Keith, 1991). Despite the philosophical impor­tance of the team approach in a rehabilitation setting, individ­ual team members' identities frequently are narrowly focusedon their specific discipline (Strasser et al., 1994).

The picture within a picture: The rehabilitationnurse

As a result of their prospective study ofrehabilitation nurs­ing roles, Brillhart and Sills (1994) reported that nurses wereengaged in activities related to team collaboration, plannedwork, goal-directed work, and communication. Nurses func­tioning as case managers within a team had access to informa­tion about coping abilities, the availability of resources, andclient support systems, as well as an understanding of the client'sphysical, psychosocial, and spiritual functioning (Tahan, 1993).

O'Toole (1992) suggested that nursing leadership within aninterdisciplinary team has the potential to facilitate team func­tion by providing factual data gathered through direct daily,around-the-clock experience. For example, a physiotherapistmay report in an interdisciplinary team meeting that a client isable to transfer independently when he is in the physiotherapytreatment area. Nurses, however, may report that after a longday of activities, the same client requires moderate assistanceto transfer safely during the evening hours. This difference inobservations can have a significant impact on discharge planningand is information that only nurses are able to contribute. Theinformation that the nurse in this example provides about theclient's abilities might prompt the physiotherapist to modifythe treatment plan.

Despite having an extensive knowledge base about clients,nurses have been observed to be uncomfortable with their roleduring team conferences. One observer, for example, noted thatnurses tend to provide only perfunctory task-oriented informa­tion related to bowel and bladder care (O'Toole, 1992).

Bradford (1989) suggested that a lack of assertiveness edu­cation has led nurses to be passive receivers of information inteam settings. Passive behaviors do not lead nurses to assumean advocacy role on behalfof clients or to facilitate team func­tioning through a nursing leadership role.

In their examination of the role of nurses in medical wardrounds, Busby and Gilchrist (1992) found that nurses believedthey were more knowledgeable about all aspects of clients' carethan were any other team members and that they actively func­tioned as client advocates within the team process. In contrast,independent observers involved in this study reported that nurs­es made limited contributions to ward round discussions andusually sought clarification of medical issues when they didcontribute. Clients interviewed during this study indicated thatnurses did not have the knowledge necessary to respond to theirquestions adequately. Clients regarded the physician as the pri-

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mary source of information.Mallick (1992), in a small descriptive study of the role of

nurses during interdisciplinary team conferences, noted that al­though nurses spent more time than other team members in di­rect interactions with clients, they contributed minimally interms of authoritative statements regarding clients' progress.Nurses in Mallick's study ranked their contributions to client­centered activities as high; however, independent observersranked them low in this capacity.

In an examination of rehabilitation nurses' levels ofjob sat­isfaction, Purk (1993) found that rehabilitation nurses felt thatcommunication among interdisciplinary team members was in­adequate and that they often felt uninformed and undervalued.Nurses in this descriptive study perceived that their educationhad left them inadequately prepared for rehabilitation nursingand participation in the team process. Hoeman (1989) calledfor the development of models for rehabilitation nursing edu­cation and an improvement in the quality of education in orderto improve client outcomes related to rehabilitation nursing in­terventions. Mariano (1989) suggested that increased collabo­ration among healthcare providers would be a route to enhanc­ing client care outcomes. O'Toole (1992) suggested that ifnursesare to be fully prepared for interdisciplinary team participation,they must be empowered.

Nurses' astute, unique observations providedduring team meetings can have a significant

impact on discharge planning.

Ideally, basic nursing programs would prepare nurses for in­terdisciplinary team participation by including opportunitiesfor practicing team collaboration, actively participating in groupdiscussions, and focusing on communication skills. At the grad­uate nursing level, specific courses of study related to the roleof rehabilitation nurses within the interdisciplinary team couldhelp to bridge the gap between basic nursing education andpractice expectations in clinical settings. Examples of specificcurricula are those leading to the Certified Rehabilitation Reg­istered Nurse (CRRN) credential and the CRRN-Advanced(CRRN-A) credential.

Nursing education in team participation is perhaps most ef­fective when it is an active, reflective process that incorporatesopportunities for leaming based upon nurses' own experiences.To improve both the quality of information provided to inter­disciplinary rehabilitation teams and the quality of nurses' par­ticipation in the team process, nurses must become skilled inexamining their own practices. To this end, clinical supervisioncould be viewed as an innovation within rehabilitation nursingpractice. Clinical supervision, although used extensively in psy­chiatric/mental health nursing settings, has not been widelyused in rehabilitation settings.

Clinical supervision as an educational strategyClinical supervision facilitates the learning of skills. Thera­

peutic skills must be practiced. Clinical supervision requires

nurses to review their work with an experienced senior clini­cian who is able to facilitate objective self-evaluation (Platt­Koch, 1986). As cited in Maki and Delworth (1995), Bernard andGoodyear (1992, p. 284) defined clinical supervision as an in­tervention that is provided by a senior member of the profes­sion to a junior member of that same profession. This relation­ship is evaluative, extends over time, and has the simultaneouspurpose of enhancing the professional functioning of the juniormember by monitoring the quality of the professional servicesthe junior member offers to clients.

Clinical supervision can provide a frameworkfor determining what information is relevant

to the interdisciplinary team.

Clinical supervision can provide a structure for organizing in­formation to enhance nurses' understanding of clinical con­cepts and can provide a framework that helps to describe andanalyze observations at an increased skill level (Critchley, 1987).The process of clinical supervision provides an opportunity toexplore and objectively analyze the interactions that occur be­tween a client and a nurse. It seeks to clarify the goals ofther­apeutic interactions and helps nurses focus on aspects of thenurse-client relationship of which they may not have been cog­nizant (Minot & Adamski, 1989).

Reflection is an important tool in the clinical supervisionprocess. Schon (1987) described the process of reflection in ac­tion, in which a reflective practitioner begins to question roteresponses and assumptions. This process affords practitionersopportunities to restructure their strategies in action, understandphenomena, and reframe problems. Skilled reflective practi­tioners develop the ability to adjust their interactions from mo­ment to moment on the basis of the feedback they receive.

By engaging in a clinical supervision process, nurses candevelop skills in self-reflection that should lead to an exami­nation of their individual skills and knowledge. Nurses learnthrough this process to reflect on the nurse-client relationship,examine alternative interventions, and to consider outcomes.This process may be centered on the most complex cases inwhich the nurse is engaged. The self-knowledge nurses can gainfrom the clinical supervision process can provide a skill set thatcan be transferred to any client interaction. As nurses examinetheir clinical practices, reflection on their actions can begin toshape all of their interactions with clients. As nurses increasetheir ability to understand the impact of their thoughts, feelings,and responses in clinical situations, they may be better preparedto support clients throughout the challenging rehabilitationprocess.

Like professionals in other health disciplines, nurses bring tothe interdisciplinary team a wealth of knowledge and a varietyof clinical issues. Clinical supervision can provide a frameworkfor determining what, from a broad scope of information, is rel­evant to the interdisciplinary team. Furthermore, the clinicalsupervision process may help nurses to better determine the

questions to which they will be expected to give concise an­swers. Recognizing the difference between relevant and super­fluous clinical information and tailoring reporting structuresaccordingly will help nurses to consistently provide concise,relevant data. Given the scope of their involvement with clients,rehabilitation nurses should be well positioned to provide andreceive quality information when working within an interdis­ciplinary team. The following case example illustrates how theprocess of clinical supervision can facilitate and enhance teamreporting.

Case exampleTraditional nursing contributions to the team confer­

ence: This is how a nurse might report on a client's progressduring a typical interdisciplinary team conference:

John M. has been experiencing severe constipation andconsistently fails to complete his bowel program. Heneeds to be encouraged to get up in the morning, but heprefers to stay in bed until noon. He speaks only whenhe is spoken to. His lack of progress is frustrating.Clinical supervision intervention: A nurse who is partic-

ipating in a clinical supervision process would discuss this clin­ical situation with an advanced practice nurse who is servingas the clinical supervisor. The clinical supervisor would thenask reflective questions to encourage the nurse to view the sit­uationfrom alternative perspectives. For example, the clinicalsupervisor might ask the nurse about what the client is doingor not doing, as well as about what the nurse is doing or not do­ing. The clinical supervisor would explore the influence thatthe nurse's behavior might have on the client and the influencesof the client's behavior on the nurse. These questions wouldhelp facilitate the nurse's examination of the clinical situationin terms of the nurse-client relationship.

More specifically, the clinical supervisor might ask thesequestions:

When John does not complete his bowel program, whatdo you do? Have you noticed anything about John's re­sponse to your nursing care? What do you think are someof the issues preventing John from completing his bow­el program? How does John show his frustration? Whatstrategies might you and John work on together to de­crease the frustration?Nursing contributions to the team conference after clin­

ical supervision: The following is a comprehensive report thatthe nurse would give during the interdisciplinary team meetingas a result of participating in the clinical supervision process:

John M. and I have discussed his rehabilitation goals re­lated to bowel care. While John understands the need fora thorough bowel program, he often feels overwhelmedby his care needs. I find that I have to schedule time to as­sist John with his bowel program and also talk about hisfeelings, otherwise we both feel rushed and frustrated.John has agreed that he will complete his bowel programbefore 10 am. He prefers not to be awakened until 8 am,and we need to talk about the possibility of rearranging

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his physiotherapy schedule to accommodate this changein routine. I have discussed with the other staff John'sneed for private time so that he can come to grips with hisinjury. John says that he continues to require social worksupport, as he often feels very sad. John has agreed tomake these arrangements with the social worker.This case example illustrates the difference that clinical su­

pervision can make. In this example, the nurse demonstrated afocus on the nurse-client relationship, identified contextual is­sues that have an impact on the clinical supervision, and pre­sented possible strategies involving the entire interdisciplinaryteam.

SummaryThe potential benefits of clinical supervision for rehabilita­

tion nurses requires study; however, nurses can benefit fromopportunities to reflect on practice issues through this process.To improve the quality of their contributions to the interdisci­plinary team process, nurses must stand back from the largerpicture and reflect upon the picture within the picture. Reha­bilitation nurses can learn to think about their interactions withclients in new creative ways by introducing learning activitiesused within other areas of nursing, such as clinical supervision.Rehabilitation nurses can realize their full potential as contrib­utors to the interdisciplinary team process when they reflectupon their practice-a skill that can be learned and enhancedthrough the clinical supervision process.

Christine Anderson is the program director ofrehabilitation andJan Park Dorsay is a rehabilitation clinical nurse specialist atHamilton Health Sciences Corporation in Hamilton, ON, Canada.

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role conflicts. Rehabilitation Nursing, 20,204-211.Bradford, R. (1989). Obstacles to collaborative practice. Nursing Man­

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round. Journal ofAdvanced Nursing, 17,339-346.Critchley, D.L. (1987). Clinical supervision as a learning tool for the ther­

apist in milieu settings. Journal ofPsychosocial Nursing, 25(8), 18-22.Diller, L. (1990). Fostering the interdisciplinary team: Fostering research

in a society in transition. Archives ofPhysical Medicine and Rehabilitation,71,275-278.

Hoeman, S. (1989). Testimony on behalf of rehabilitation nursing before theRehabilitation Services Administration. Rehabilitation Nursing, 14,338-340.

Jaffe, B., & Walsh, P. (1993). The developmentof the specialty rehabilitationhome care team: Supporting the creative thought process. Holistic NursingPractice, 7(4), 36-41.

Keith, R.A. (1991). The comprehensive treatment team in rehabilitation.Archives ofPhysical Medicine and Rehabilitation, 72, 269-274.

Maki, D., & Delworth, U. (1995). Clinical supervision: A definition andmodel for the rehabilitation counseling profession. Rehabilitation CounselingBulletin, 38,282-287.

Mallick, M. (1992). The role of the nurse on the consultant's ward round.Nursing Times, 88(5),49-52.

Mariano, C. (1989). The case for interdisciplinary collaboration. NursingOutlook, 37, 285-288.

Minot, S.R., & Adamski, T. (1989). Elements of effective clinical super­vision. Perspectives in Psychiatric Care, 25(2), 22-26.

O'Toole, M.T. (1992). The interdisciplinary team: Research and educa­tion. Holistic Nursing Practice, 6(2),76-83.

Platt-Koch, L. (1986). Clinical supervision for psychiatric nursing. Jour­nal ofPsychosocial Nursing, 26(1),7-15.

Purk, J. K. (1993). Rehabilitation staff nurses' job satisfaction. Rehabili­tation Nursing, 18,249-252.

Ragnarsson, K.T., & Gordon, W.A. (1992). Rehabilitation after spinal cordinjury. Physical Medicine and Rehabilitation Clinics ofNorth America, 3, 853­876.

Rothberg, J. (1981). The rehabilitation team: Future direction. Archives ofPhysical Medicine and Rehabilitation, 62, 407-410.

Schon, D. (1987). Educating the reflective practitioner. San Francisco:Jossey-Bass.

Strasser, D., Falconer, J., & Martino-Saltzmann, D. (1994). The rehabili­tation team: Staffperceptions of the hospital environment, the interdisciplinaryteam environment, and interprofessional relations. Archives ofPhysical Med­icineandRehabilitation, 75, 177-182.

Tahan, H. (1993). The nurse case manager in acute care settings. JournalofNursing Administration, 23(10), 53~61.

Warner, U. (1993). Improving input to case conferences. Nursing Stan­dard, 17(7),33-34.

Volunteer for the ARN Continuing Education Review PanelThe ARNContinuing Education Approval Committee is looking for members to serve on the Continuing EducationReview Panel. Volunteers must meet the following qualifications:

• Must be an ARNmember in good standingand be knowledgeable and supportive of thephilosophy and goals of the association

• Must have at least a bachelor of sciencedegree in nursing (graduate degree preferred)

• Must have experience with planning, develop­ing, implementing, and evaluating continuingeducation activities for adult learners

• Must exhibit expertise in one or more areas ofrehabilitation nursing

308 Rehabilitation Nursing> Volume 23.,Number 6 • Nov/Dec 1998

If you have these qualifications and are inter­ested in serving on the ARNContinuing Educa­tion Review Panel, please submit a current cur­riculum vitae and a letter of interest specifyingyour practice interest to

ARNCERP4700 W. Lake AvenueGlenview, IL60025-1485