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nurse, supervision, experience, head nurse, outpatient, qualitative study
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Ningsih R, Setyowati S, Gayatri D et al. A qualitative study of the experience of head nurses in supervising nursing staff in the outpatient department [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:1106 (https://doi.org/10.12688/f1000research.155970.1)
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Research Article
A qualitative study of the experience of head nurses in supervising nursing staff in the outpatient department
[version 1; peer review: 1 approved with reservations]
PUBLISHED 30 Sep 2024
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Abstract
Corresponding author:
Setyowati Setyowati
Competing interests:
No competing interests were disclosed.
Grant information:
We would like to acknowledge the financial support received support from the Lembaga Pengelola Dana PendidikanThe Center for Higher Education (BPPT) and Indonesia Endowment Funds for Education, Ministry of Finance of Indonesia ., through their scholarship program
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2024 Ningsih R et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Ningsih R, Setyowati S, Gayatri D et al. A qualitative study of the experience of head nurses in supervising nursing staff in the outpatient department [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:1106 (https://doi.org/10.12688/f1000research.155970.1)
First published: 30 Sep 2024, 13:1106 (https://doi.org/10.12688/f1000research.155970.1)
Latest published: 30 Sep 2024, 13:1106 (https://doi.org/10.12688/f1000research.155970.1)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
The role of head nurses within the healthcare unit is crucial in motivating and supervising nursing staff to maximize performance and achieve the vision and mission of the organization.1 However, a prevalent issue persists where a notable number of them exhibit deficiencies in providing adequate encouragement, motivation, and supervision, leading to suboptimal supervision.2
Head nurses frequently experience significant stress levels due to the multifaceted nature of their responsibilities, encompassing both clinical and supervisory roles.3 The primary sources of stress can be attributed to various factors, such as staff shortage (94.4%), poor working conditions (91.8%), inadequate management support (89.9%), and heavy workload (89.15%). Furthermore, these conditions affect their ability to effectively perform supervisory duties to nursing staff.4
This current study marked a pioneering endeavor in Indonesia, where the majority of previous nursing management studies on supervision only examined the relationship between supervision, patient safety, and work enthusiasm.5 The experience of head nurses while performing their roles has only been reported in the inpatient setting, particularly during the COVID-19 pandemic.6 A previous study was conducted in Southern Ireland on all supervisors across the hospital to assess their experience but was not specific to the outpatient department.7 Insufficient supervision within healthcare units can lead to a lack of adherence among nurses to established procedures.8 Therefore, this study aims to explore the experiences, perception, and expectations of head nurses to gain knowledge into nurse performance evaluation and clinical supervision in the outpatient department.
Methods
Study design
This study was carried out using the consolidated criteria for reporting qualitative study (COREQ). Furthermore, the procedures used an explanatory phenomenology design, and data collection was performed using focus group discussion (FGD). A qualitative method primarily focused on exploring the significance to gain a deeper understanding of various aspects of life.9 The method often used an inductive and descriptive method to describe problems and reflect human experience in complex situations.9 Due to the limited number of reports examining the experience of head nurses while supervising treatments in the outpatient department, this study aimed to address this gap. The outpatient department served as the frontline of the hospital, as all patients in need of treatment must first go through the unit. Consequently, it became imperative to enhance the quality of nursing services provided in this context.
The study procedure started with the collection of general demographic data and clinical information of head nurses, such as age, gender, and professional title. Subsequently, an evidence-based Focus Group Discussion was developed to collect more data. The discussion questions were initially structured using a literature review,6,10 and then revised after consulting four qualitative experts. The interview questions included:
(a) What do you know about clinical supervision?
(b) What have you done regarding the supervision of road maintenance?
(c) How was your experience as a road-treated supervisor?
(d) What obstacles did you feel as a road care supervisor and what kind of support did you get?
(e) What are your hopes for the supervision of the nursing clinic to be treated in the future?
Participant
The purposive sampling method was used to recruit individuals who could provide more valuable and appropriate information to the study questions. The sample population consisted of head nurses serving in the polyclinic rooms of state and private hospitals in West Sumatra Province, Indonesia. Furthermore, the recruitment of participants was stopped when the saturation of information was achieved or no new information was obtained.11
Data collection
Data from this study were collected using FGDs, which spanned 45 to 60 min, with an average of 52.5 min. All FGDs were completed between the 13th and 29th of October, 2022. This study aims and procedures were explained to the participants before the discussions to obtain their audio-recorded informed consent. The discussion recording and other materials were kept on two password-secured computers, which were placed separately. To protect the privacy of the participants, they were all given a subject ID (e.g. P1 = Participant 1). The participants were then asked to describe their experiences of clinical supervision in the outpatient department. During the FGD, the questions were not limited to only the interview outline to obtain more information while striving to make the discussion feel natural. Furthermore, interview techniques, such as repetition, clarification, induction, and summary were used to obtain in-depth information.12
Data analysis
Within 30 hours after the interview, the recorded materials were organized, analyzed, summarized, and further supplemented with field notes. The recordings were transcribed word for word using computer software. During the transcription, some notes were made regarding the details of the modal word and pauses of the interviewees. Furthermore, transcripts were uploaded to Nvivo to store, manage, and analyze the data within 30 hours after the interview. Interpretative phenomenological analysis (IPA) was used during the data analysis process.10,13 The IPA included re-reading textual material, preliminary annotation and analysis, generating themes, thinking about the inter-topic association, analyzing the next case, and exploring inter-case thematic connections. The analysis was carried out to clarify the themes and the relationships among them. The process was then continued with coding, classifying, explaining the essential meaning of the phenomenon, and refining the central themes. The themes extracted from the final collation code were sent back to the participants to confirm whether the items indeed expressed their feelings.
Results
This study recruited a total of 20 head nurses in public and private hospitals in West Sumatra province, as shown in Table 1. The FGD (focus group discussion) data were analyzed and coded using a total of 102 nodes. Furthermore, the nodes were used to generate 5 themes and 16 subthemes. The five major themes included the knowledge of head nurses about supervision, the performance appraisal method, the feeling of head nurses when supervising, the supervisor support for supervision, and the expectations of head nurses towards supervision in the outpatient department.
Table 1. Participants.
Theme 1: The knowledge of head nurses about supervision
Knowledge of supervision
The duties, roles, and responsibilities of nurses can be measured. This statement underscored the idea that the knowledge of head nurses about supervision was an effort to provide direction to staff, thereby improving the quality of the provided service.
‘I think the supervision of the nursing clinic is an effort to provide direction to staff by evaluating the work and knowledge of staff’. (P1)
‘In my opinion, the supervision of the nursing clinic is not to find fault with staff but rather to provide direction for service improvement’. (P12)
What to do during supervision
When the practice of supervision was carried out in this manner, the head of the room directly supervised nursing staff.
‘Sometimes as head of the room, I carry out direct supervisionto nurses if there is free time’. (P4)
‘During supervision, I give directions to nursing staff if there is work. Nursing staff who do not comply with procedures’. (P2)
Theme 2: Performance appraisal methods
Individual performance indicators
All participants stated that the performance appraisal method employed involved the use of individual performance indicators.
‘The method used to measure the performance of nurses is the Individual Performance Indicators’. (P4)
‘The performance of nurses is measured using individual performance indicators that have been provided by the hospital’. (P10)
Four individual performance indicators, namely quantity, quality, behavior, and additional activities
All participants stated that the four indicators of individual performance included quality, quantity, behavior, and additional activities.
‘Among the four indicators assessed is quantity, which is the number of patients cared for in one day’. (P2)
‘Quality in my opinion is the quality of nursing care provided to patients, including nursing care supervision, nursing action supervision, and others’. (P3)
How to assess performance with logbooks, documents, supervision, and nursing rounds
The participants carried out performance appraisals by assessing logbooks, documents, and nursing rounds.
‘I think the way to assess an individual performance is by doing supervision, nursing rounds, etc’. (P5)
‘How to assess individual performance includes looking at the logbook made by the nurse. By looking at the logbook, the number of patients given nursing care will be used for the quantity indicator’ (P16).
Theme 3: The feeling of head nurses about supervision
Feelings of disappointment
The participants stated that they experienced feelings of disappointment when supervising the practicing nurses.
‘The experiences are different among them, I have heard that when I do the supervision, I am considered to find fault by the implementing nurse’. (P1)
‘It is the same, I have also received a report that during this supervision, I was considered to be looking for errors to reduce the quality performance indicator value.’ (P4)
Participants are indifferent
Based on the interview results, the majority of the respondents were indifferent after supervision.
‘I just want to do the usual, when supervising it is up to them whether they consider me something, I am indifferent. If they feel I give knowledge, thank God, if not, okay for yes, the important thing is that I have fulfilled my obligations’. (P6)
Feelings are useful because they provide input and new knowledge. The participants believed that feelings were useful because the supervised nurses received input and gained new knowledge.
‘I have an experience, after the supervision I was given appreciation by the nurses and they said that they gained new knowledge, he told me’. (P2)
‘Maybe because the nurses in my room are young, they accept being supervised, and feel they are being briefed’. (P3)
Theme 4: Supervisor support for supervision
Have the support of supervisors
The implementation of supervision garnered complete support from supervisors, as well as all relevant stakeholders within the hospital. The director, head of fields, and all officials with nursing-related interests supported the supervision activities of the clinic.
‘I think all parties support the implementation of this supervision’. (P4)
‘That is right, I think all parties support the implementation of this supervision, the most supportive supervisors, our rich example wants to ask atk for the implementation of supervision, wow directly in acc and given it, ma’am’. (P6)
The first obstacle to supervision is the lack of a supervision format
Road maintenance supervision had no standard format and was only carried out by writing notes in books.
‘During my time as head nurses here, there was no standard supervision format given from the top of the nursing department’. (P1)
‘That is right, we carry out the supervision with a thick 100-piece book, then we write down the name of the supervisor, the items supervised, then the input and direction’. (P3)
The second barrier to supervision is limited time and energy
‘Sometimes we want to carry out this supervision, but head nurses has a lot of activities. Therefore, with the busyness of the meeting and the duties of head nurses, finally the supervision is not carried out’. (P1)
‘Because there are many patients in this polyclinic, even up to 200 people every day, and this is not covered by nurses who are only a few people in each polyclinic, head nurses must also intervene to serve patients in the polyclinic book, this is the reason why supervision is not carried out’. (P3)
Theme 5: The expectation of head nurses towards supervision
Simple supervision
A total of 3 out of 6 participants expected the supervision to be simple, without many procedures.
‘Honestly, I want to carry out this supervision, but because of these obstacles, sometimes supervision is not carried out, hence, I suggest this supervision can be made simpler’. (P1)
‘Maybe if this supervision is simple, it means that it is already available from the beginning of the schedule, the name to be supervised, the items to be supervised, hemce, there is room to carry out the supervision’. (P5)
‘I agree, I also want this supervision to be simple, hence, the supervisor is more comfortable to carry out supervision’. (P6)
Supervision that does not take much time
A total of 2 out of six respondents stated that desired less time-consuming supervision.
‘I would like the supervision not to take a lot of time. Head nurses are already busy, hence, if possible, this supervision does not take much time’. (P3)
‘It is the same book, hence, it does not take much time for other work to be done, supervision goes well, subsequently open the wish’. (P6)
Objective supervision
The results showed that 3 participants expected objective supervision.
‘As a supervisor, I expect this supervision to be objective because it prevents experience, where head nurses are mistaken for finding fault with the nurse’. (P1)
‘That is right, it is expected to be objective, hence, the nurse can see directly if there is an assessment and there is a standard in the supervision, she can see for herself and realize for herself where it is wrong and lacking because it does not come from head nurses but has been arranged by the system or something to assess the ability of this nurse in this supervision’. (P4)
‘I also want this supervision to be objective, for example, the things that are supervised have a direct list of points, and there are value points directly there. Therefore, if that is the case, those who are supervised will not think there is a subjective judgment, right’. (P6)
Need for technological support
A total of two respondents stated that they preferred technology-assisted supervision.
‘In my opinion, perhaps there is also a need for technological assistance for the implementation of this supervision. Later, if it is done with technology, subjectivity will not exist, certainly, the assessment will be more objective, then there can be made a reminder that will remember, today head nurses will supervise, who and what items will be supervised, and with technology, I think it can be made simpler, ma’am’. (P1)
‘If the supervision had been done with technology, I am sure that no one would say that this supervision is just finding mistakes.’ (P6)
‘Probably representing us here, we want this supervision to run well without interfering with other work, and if possible, this supervision to keep up with the times’. (P17)
Discussion
Supervision is one of the core aspects of nursing services, ensuring that the care provided to patients by nurses adhered to standard procedures. The experience of head nurses in supervising other nursing staff is important, as it could provide knowledge. Furthermore, the higher the knowledge, the better the service provided to patients. The level of knowledge of nurses about performance had a positive impact on patients. This was because higher levels in head nurses could facilitate performance improvement, thereby helping in avoiding unexpected events among homebound patients.14 The results showed that head nurses in this study had a good level of knowledge about outpatient performance. This was expected to motivate other nursing staff to carry out nursing care properly, thereby increasing the quality of the provided service.
According to this study, the emotions of head nurses during the supervision process were occasionally misconstrued as fault finding. This misunderstanding sometimes led to feelings of disappointment, as the process was often considered an exercise in identifying errors. These findings were consistent with a previous study, where head nurses experienced physiological effects due to their supervisory roles. However, it was imperative for them to adopt an approach that emphasized the constructive implementation of the supervisory function.15 The results were inconsistent with some studies, where head nurses often experienced a sense of relief, as supervision was considered a process that could provide feedback for service improvemen.16
Based on the analysis results, supervision must not be carried out to find faults/shortcomings of nursing staff. Moreover, the urgency attached to the need for the process must be carefully examined, as its hasty execution could potentially trigger feelings of anxiety, disappointment, or a sense of being unfairly targeted by the supervisors. It was also imperative to recognize that supervision must not be wielded as a tool of power, rank, position, or personal authority. In this context of a hospital setting, supervisors were expected to shed their hierarchical role and relinquish any air of superiority. This entailed figuratively discarding the “jacket of rank” during the process. Consequently, this process allowed for the establishment of an atmosphere that encouraged close partnership, making nursing staff more comfortable with the supervisors and their judgment.
Supervision activities were not only carried out based on the desire and time of the supervisors but were conducted based on the predetermined schedule. This structured approach was to accommodate the needs of nursing staff conducting fieldwork, ensuring that the supervision was efficient and minimally disruptive to their daily tasks. The process must also be carried out objectively and impartially, without favoritism. Supervision must be continuous, enabling the measurement of progress and the resolution of the challenges faced by measured or the resolution of problems faced by out-of-care nurses. The incorporation of technology could significantly enhance the objectivity of the process. The quality or quality of nursing care implementation was expected to increase when effective and continuous supervision was carried out by supervisors at the hospital.17
This study provided knowledge into the experiences of head nurses in various dimensions. One notable observation was that nursing staff often perceived the action of head nurses as fault-finding, leading to the anticipatation of low assessment scores. The results also showed instances where the participants were indifferent, possibly due to the perception that their duties were concluded after supervision. Meanwhile, some participants experienced the feeling that they actively imparted knowledge and guidance to nursing staff. All the respondents in this study expressed a sense of responsibility, pride, and professional honor that reflected their self-worth.
Limitation
There were several limitations in this study, including the difficulty encountered while convening meetings with the participants due to the ongoing pandemic conditions. The Indonesian government was still enforcing the Covid-19 policy, and this caused constraints during face-face discussions, leading to prolonged interaction. Furthermore, head nurses, tasked with multiple duties, often encountered scheduling conflicts, leading to delays or rescheduling of discussions. This study also used a small sample size, thereby necessitating the use of a larger population in future studies.
Implication
This study highlights that the experience of head nurses significantly impacts the quality of supervision provided to nursing staff in the outpatient department. Consequently, the implication of these findings is the need for enhanced training and education for head nurses to deepen their understanding of effective supervisory techniques and performance assessment methodologies. By providing better training, it is anticipated that head nurses will improve their supervisory effectiveness, reduce staff perceptions of supervision as merely a fault-finding process, and ultimately contribute to better overall nursing care.
Recommendations for further research
It is recommended to explore the experiences of head nurses in different healthcare settings, such as inpatient departments, to compare and contrast supervisory practices. Additionally, a larger sample size and the incorporation of advanced technological tools in supervision could provide more comprehensive insights into improving nursing care quality.
Ethics and consent
This study was approved by the Ethics Committee of the Faculty of Nursing, Universitas Indonesia, with reference number KET-254/UN2.F12.D1.2.1/PPM.00.02/2022, issued on October 6th, 2022. In this study, participants voluntarily written signed consent forms after being informed about the procedures, objectives, benefits, risks of harm, rights, and obligations of the participants through a research explanation sheet. They were assured of their voluntary participation and informed of their right to withdraw from the study at any time without penalty. The consent form outlined the confidentiality measures in place to protect their identity and data. Participants were encouraged to ask questions and seek clarification before providing consent.
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how to cite this article
Ningsih R, Setyowati S, Gayatri D et al. A qualitative study of the experience of head nurses in supervising nursing staff in the outpatient department [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:1106 (https://doi.org/10.12688/f1000research.155970.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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How to cite this report:
Abou Hashish EA. Reviewer Report For: A qualitative study of the experience of head nurses in supervising nursing staff in the outpatient department [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:1106 (https://doi.org/10.5256/f1000research.171215.r338603)
The direct URL for this report is:
https://f1000research.com/articles/13-1106/v1#referee-response-338603
https://f1000research.com/articles/13-1106/v1#referee-response-338603
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 12 Aug 2025
Approved with Reservations
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Reviewer Report
Title: A qualitative study of the experience of head nurses in supervising nursing staff in the outpatient department
Overall assessment
The manuscript addresses an important and underexplored topic in nursing management, particularly within ... Continue reading
Title: A qualitative study of the experience of head nurses in supervising nursing staff in the outpatient department
Overall assessment
The manuscript addresses an important and underexplored topic in nursing management, particularly within ... Continue reading
CITE
HOW TO CITE THIS REPORT
Abou Hashish EA. Reviewer Report For: A qualitative study of the experience of head nurses in supervising nursing staff in the outpatient department [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:1106 (https://doi.org/10.5256/f1000research.171215.r338603)
The direct URL for this report is:
https://f1000research.com/articles/13-1106/v1#referee-response-338603
https://f1000research.com/articles/13-1106/v1#referee-response-338603
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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