Testing Construct Validity of the Clinical Supervision Scale in Intensive Care Units at Tertiary Care Hospitals in the Northeast of Thailand

Background and significance of the problem

Clinical supervision is an important process for developing and supporting health professionals in providing quality services according to professional standards and ensuring patient safety of patients (Snowdon et al., 2020). It is part of the nursing management system, which is an important tool in developing nurses’ knowledge, skills, and competencies to work to meet professional standards, leading to patient safety and satisfaction (Supunpayob, Sukadisai & Amphon, 2013). Clinical supervision processes and supervisor training have received widespread attention worldwide. As a result, a large number of studies have provided greater specifications for effective clinical supervision practices and supervisors (Milne & Watkins, 2014). The same is true for Thailand. Various supervision styles have been developed (Phanjungharn & Juntachum, 2022). The Proctor’s model of clinical supervision is a popular concept. Clinical supervision is the process by which head nurses assist and encourage registered nurses to develop their knowledge, abilities, and skills in nursing practice and recognize individual differences by using a thinking process to create continuous learning. As a result, patients can receive standard nursing practice, and goals can be achieved.

The intensive care unit (ICU) provides care for critically ill patients. Close care focuses on providing treatment, palliative care for both physical and mental health, and the prevention of complications or potential danger to the patient’s life, which includes unplanned activities, urgent situations, stressful environments, and high mortality rates (Guidet & González-Romá, 2011). Therefore, to provide good nursing quality and outcomes that focus on maximizing patient safety, ICU nurses need specialized knowledge, skills, and experience to provide timely and appropriate care to critically ill patients with complex care problems (Stone et al., 2009). As a result, clinical supervision is an important mechanism for supporting professional practice. Participatory supervision allows supervisees to exchange knowledge and work experience in terms of management and clinical practice. This helps nurses develop skills in applying the nursing process and recognize nursing outcomes, leading to the prevention of complications or adverse events (Limtrakul, 2019; Phanjungharn & Juntachum, 2022).

Proctor (2001) described clinical supervision as the process by which supervisors treat their supervisees through interpersonal relationships with the aim of helping supervisees develop their knowledge of their ability to perform clinical duties to provide quality service. Supervision focuses on work, people, and participation in collaborations. In all nursing supervision activities, supervisors can intervene in the supervision process. This will make nurse supervisors proud, resulting in a positive impact on nursing practice (Proctor, 2001 cited in Driscoll, 2007). Proctor’s model of clinical supervision consists of three aspects: 1) normative function: supervision based on the current principles, guidelines, and standards of care; 2) formative function: supervision to help increase knowledge, skills, and expertise and promote learning through reflection; and 3) restorative function: supervision based on generosity, understanding, and good interpersonal relationships and creating a good atmosphere for the supervisees to have a good attitude and reduce stress (Hawkins & Shohet, 2012). Supervisees will be encouraged to develop their professional skills, respond to organizational needs, and manage emotional states on the job. Emphasis was placed on reflective supervision. Supervisors reflect on the cognitive and emotional performance of supervisees (Snowdon et al., 2020).

From a review of the research papers related to clinical supervision in Thailand, it was found that most of the research was to develop a supervision model by applying Proctor’s concept in accordance with the needs of the organizational context, as follows. Limtrakul (2019) developed a nursing supervision model of anesthesia for service standards and quality, consisting of the following supervision functions: 1) Formative supervision: Supervision activities included nursing conferences, nursing rounds, instruction, advice, observation, and participation in practice. 2) Nominative supervision: Supervision activities included nursing rounds, instruction, and reflection in written form. 3) Restorative supervision: Supervision activities included providing advice, problem-solving, and nursing conferences. After the development of the supervision model, the knowledge, attitude, supervision practice skills, and satisfaction of the nurses with the supervision model were significantly higher than before the model was developed at the .05 level. Phanjungharn and Juntachum (2022) developed a nursing supervision model for cancer patients receiving chemotherapy at Udonthani Cancer Hospital. The proctors’ three functions of clinical supervision were integrated for model development. The developed supervision model consisted of: 1) standards of care for the safety of cancer patients receiving chemotherapy, 2) contract and participation in the supervision plan, 3) supervision action for the development of professional knowledge and skills, 4) reflection for feedback, and 5) supportive function. After the implementation of the supervision model, nurse supervisees’ competency scores were significantly increased at a 0.5 level, compared to those before the implementation of the model, leading to effective nursing outcomes and patient safety. In addition, the relationship between two variables, supervision and nursing quality or nursing outcomes and risk management process and nursing outcomes occurring among both patients and nurses, was also studied. The effect size of supervision on nursing outcomes in terms of patient safety was moderate to high (r = 0.69-0.76, d = 0.91-1.01) (Tripitak, 2008; Iamakad, 2010). The effect size of clinical risk management on nursing outcomes was moderate to high (r = 0.54-0.92, d = 1.93-2.27) (Joongthai, 2016; Pongchanwit, 2020; Van Gaal et al., 2014). There are also recommendations from previous research that nursing supervision through the risk-management process results in patient safety and leads to desirable nursing outcomes (Wanthanathat et al., 2018). This reflects the relationship between the variables, which indicates that clinical supervision directly and indirectly affects nursing outcomes through the risk management process. In addition, the studied variables consisted of both latent and observed variables.

However, from the literature review, it was found that a tool for assessing supervisors’ clinical supervision has not been clearly developed, especially in the context of the ICU, which requires close supervision and monitoring of nurses to provide the highest level of safety for patients. Therefore, Research objective to analyze the construct validity of the clinical supervision scale in the intensive care units at the tertiary hospitals in the Northeast of Thailand by exploratory factor analysis and confirmatory factor analysis. The testing of construct validity of the clinical supervision scale in intensive care units developed based on the framework of Proctor’s model will be the basic guideline for nursing supervisors in the supervision of nurses according to their supervisory roles, leading to the development of effective clinical supervision tools in the future.

From the literature review, many studies used the framework of Proctor’s clinical supervision model (2001) to improve the quality of care, relationship, and quality of nursing care documentation. Brunero and Stein-Parbury (2008) reviewed the available evidence regarding the effectiveness of clinical supervision in nursing practice to inform these efforts, and the reported outcomes of the studies were then categorized according to Proctor’s three functions of clinical supervision. The results of these studies demonstrated that all three functions–restorative, normative, and formative–were evident. Restorative function was noted slightly more frequently than the other two functions. The study of Yuswanto, Ernawati, & Rajiani (2018) found that Proctor’s clinical supervision model can improve the quality of nursing care documentation. Therefore, in this study, Proctor’s clinical supervision model (2001) was used as a conceptual framework.

Conceptual framework

The construct validity of the clinical supervision scale was tested based on the framework of Proctor’s clinical supervision model (2001), which consists of three functions: 1) normative function, 2) formative function and 3) restorative function. Each function consisted of six questions (indicators). The hypothesized measurement model is shown in Figure 1.

Figure 1. Conceptual framework of the hypothesized measurement model of clinical supervision in the intensive care units.

Method

This research is a study of secondary data, which is part of the research entitled “Causal Relationship Models between Clinical Supervision, Clinical Risk Management and Nursing Outcomes Perceived by Registered Nurses in Intensive Care Units, Tertiary Care Hospitals, Northeastern Thailand” conducted by the research team (Sirimontri & Juntachum, 2021). The research methodology is as follows.

Population and sample: The population included 1,208 registered nurses working in intensive care units at a tertiary hospital in Northeastern Thailand for one year or more. The sample size was determined with an effect size of 0.20, confidence level of 0.95, and power of test of 0.80. A total of 197 samples were selected for the analysis. To prevent sample loss, an additional 20% of the sample was added, so the total number of samples was 234, which covered the minimum sample size for multivariate statistical analysis (10 times of the question) (Dawson & Trapp, 2001) (there are 18 items in this study, so the minimum sample number is 180 people). Samples were selected using a multistage sampling method. Step 1: Fifty% of the hospitals were randomly selected using a simple sampling method (drawing lots) (Gall et al., 1996). Therefore, 5 hospitals from a total of 9 hospitals were selected. Step 2: The nurses in each hospital selected from Step 1 were randomly selected using a simple sampling method based on proportional allocation (Srisathitnarakun, 2007).

Data collection: Data were collection by using questionnaires, and secondary data were recorded using a data recording form. The questionnaire was constructed by the researchers and consisted of two parts: Part 1: Personal data, namely gender, education level, work experience, and clinical supervision training experience; Part 2: Clinical supervision scale in the intensive care units perceived by registered nurses constructed by the researchers based on the framework of Proctor’s clinical supervision model (2001), and the original version of the clinical supervision scale was improved by eliminating items that were highly correlated and redundant. As a result, there were 18 items (variables), consisting of 6 items of normative function, 6 items of formative supervision, and 6 items of restorative function. The choices were made on a 5-point rating scale (1-5 points), ranging from “Strongly Disagree to Strongly Agree”.

Content validity was examined by seven experts. The CVI was 1. The inter-item correlation was greater than .30, which was acceptable. Reliability was determined based on the internal consistency of the questions using Cronbach’s alpha coefficients. The overall Cronbach’s alpha coefficient for reliability was .967, while those of each aspect were .955 .950 and .945, respectively, which were higher than .70 and were considered to be within the acceptable range.

Results

The personal information of 234 samples revealed that most of them were female (95.3%) with a bachelor’s degree (95.3%) and a master’s degree (4.7%). The proportion of those with 3-5 years and more than five years of work experience was similar (29.5%). Additionally, there were nurses with 1-2 years of work experience (15%). In addition, 20.1% of participants received clinical supervision training. The mean perceived clinical supervision of registered nurses was at the highest level, which was 4.32 (S.D. = 0.58).

The construct validity of the clinical supervision scale was analyzed using exploratory factor analysis and confirmatory factor analysis. The results found that, based on the assumption of the use of factor analysis statistics, was tested by considering the statistics used to indicate the relationship between the variables. The KMO value is 0.943, indicating that the data are suitable. Bartlett’s test (Chi-square = 4888.772 df = 153 p-value = .000) showed that the correlation matrix was not an identity matrix. In addition, the variables communality ranged from to 0.724-.890, and none of them was less than 0.2, indicating that the variables were sufficiently correlated for factor analysis.

Based on factor extraction and rotation, if the factor has an eigenvalue greater than 1 and a factor loading greater than 0.50, it is considered to be at a good level (Byrne, 2010; Kline, 2016). All three independent factors had eigenvalues in the range of 1.005-11.587. The factor variance was 5% or more (26.327-27.439%). Together, they explained the variance of all variables at 81.137%, which was considered to be very good (Polit & Beck, 2012). The first factor consisted of 6 questions: items 1-6, which was named “nominative function.” The second factor consisted of 6 questions: items 7-12, which was named “formative function.” The third factor consisted of 6 questions: items 13-18, which was named “restorative function. The details are presented in Table 1.

Before the analysis, the assumption of the distribution was tested. The skewness values of the 18 questions were between -.007 and -.356, and the kurtosis values were between -.437 and -.872. Skewness ≤ 2 and kurtosis ≤ 7 indicated that the studied variables were normally distributed. The hypothesis model of clinical supervision showed goodness of fit with the empirical data obtained from the samples (chi-square value = 103.501, df = 100, p-value = .385, CFI = .999, GFI = .955, AGFI = .923, RMSEA = .012), as shown in Figure 2. The factor loading values were between .82-0.94, which indicated the construct validity of the clinical supervision scale in intensive care units. The chi-square was low, the p-value was higher than the statistical significance level of .05, and all index values were within the acceptable ranges (Kline, 2016). The hypothesize model of clinical supervision, analyzed using confirmatory factor analysis, is presented in Figure 2.

Figure 2. The hypothesized measurement model of clinical supervision in the intensive care units analyzed by confirmatory factor analysis.

Chi-square = 103.501, d.f. = 100, p-value = .385, CFI = .999, GFI = .955, AGFI = .923, RMSEA = .012.

Conclusion and discussion

Based on the exploratory factor analysis, it was found that the clinical supervision roles of supervisors in the intensive care units of General Hospitals in the Northeast of Thailand consisted of three factors as follows: Factor 1: “normative function” for development of professional accountability and quality control; Factor 2: “formative function” for skill and knowledge development and Factor 3: “restorative function” with factor loading values between .715-.859, which are greater than .50, indicating a good level (Byrne, 2010; Kline, 2016). These three factors can jointly explain the variance of all variables by 81.137%, which is an appropriate level because the number of obtained factors should explain at least 60% of the variance of all data at least 60% (Polit & Beck, 2012). These factors were consistent with Proctor’s model of clinical supervision (2001), which is a process in which supervisors treat their supervisees through interpersonal relationships with the aim of helping supervisees develop their knowledge of the ability to perform clinical duties, leading to quality services consisting of three aspects: 1) normative function, 2) formative function, and 3) restorative function. Supervisors must integrate the three aspects of supervision. When the indicator of each item was verified for construct validity using confirmatory factor analysis, which was defined as the hypothesized model, it was found to be consistent with the empirical data obtained from samples with a factor loading greater than .70. This indicates that the questions on the clinical supervision scale were good indicators. This was consistent with the reliability analysis, which indicated that the factor loading was .70, indicating that the factors could explain the variance of the studied variables up to 50% (Field, 2005; Doloi et al., 2012). It also corresponded to Cronbach’s alpha coefficient that examined the internal consistency of the questions, and found that the overall Cronbach’s alpha coefficient for reliability was .967, while those of each aspect were .955 .950 and .945, respectively, which were higher than .70 and considered to be within the acceptable range (Wells & Wollack, 2003). The details of each factor are as follows.

Factor 1: The normative function consisted of the following six questions (indicators): The organization has a clinical supervision system to improve work quality. The organization has made clinical supervision part of its activities to help improve the quality of work. The supervisor used clinical supervision criteria based on practice guidelines/WI/empirical evidence. The supervisor has a clinical supervision plan based on individual potential and competency. The supervisor has daily, monthly, and yearly clinical supervision plans, and informs the supervisees before clinical supervision. The supervisor has a system for recording supervision results and using it to develop competencies appropriately. This is consistent with Proctor’s concept of ensuring accountability or normative function, which is the practice of supporting nurses in developing their abilities that affect clinical practice by supporting the necessary resources as well as the awareness of the individual and professional differences to promote good clinical outcomes (Proctor, 2001). This requires the following important activities: support of the organization in supervising part of the work culture in that organization, taking notes, learning, and practicing on a regular basis (Driscoll, 2007). In particular, supervision in the intensive care unit, goal setting, roles and responsibilities, interactions and reflection on constructive feedback, and learning activities are needed. As a result, the organization can implement actions and gain more relevant learning (Esfahani, Varzaneh & Changiz, 2016). This is also consistent with the results of previous studies that discussed the Supervision Best Practices Guidelines that supervisors should provide supervision and follow-up following professional standards and should allow supervisees to participate in setting realistic, measurable, and practical goals in accordance with individual potential and learning needs so that the specified goals can be achieved (Borders, 2014).

Factor 2: The formative function consisted of the following six questions (indicators): The supervisor supervises/checks the quality of work according to a form such as the Braden scale. The supervisor had knowledge and expertise in supervision. Supervisors use coaching techniques to develop supervisees’ skills and decision-making skills at work. The supervisor reflects on the supervisees to realize problems/respond to incidents in a timely manner. The supervisor creatively reflects the performance of the supervisees, leading to improvement. The supervisor organized a nursing conference. This is consistent with Proctor’s concept of learning from practice or the formative function, which refers to the practice of increasing knowledge skills and the ability to perform tasks. Knowledge from theories and experiences is applied to create learning while working by using the reflection and motivation process, leading to ability development in stable relationships, resulting in good quality care for patients (Driscoll, 2007). Particularly, for the clinical supervision of supervisors in the intensive care unit, feedback from patients and colleagues, such as basic needs, comfort, and satisfaction of the patients, must be considered to improve their performance (Lindahl & Norberg, 2002). Reflections can take the form of reflective writing, group discussions, or the analysis of important events (Brunero & Stein-Parbury, 2008). Consultation groups should also be held to discuss problems arising from clinical work (Teasdale et al., 2000). Supervisors should coach supervisees so that they can use their ideas to solve problems and analyze and synthesize knowledge to create self-learning, problem-solving at work, and learning for communication, which will lead to the development of effective work (Teasdale et al., 2000; Safan et al., 2020; Juntachum et al., 2020).

Factor 3: Restorative function consists of the following six questions (indicators): The supervisor provides sufficient clinical supervision during and outside work hours. The supervisor uses empowerment techniques. The supervisor brings out supervisees’ self-awareness. The supervisor understands the individual differences. The supervisor gives advice and assistance, and is empathetic. The supervisor has active listening skills. This is consistent with Proctor’s concept of professional support or restorative function, which is the practice of providing assistance based on good professional relationships with mutual trust, equality, and understanding of differences in individual competence. Moreover, supervisors should provide time and channels for nurse supervisees to learn and develop their abilities in an appropriate environment. When supervisees have work or personal problems, they should give advice (Driscoll, 2007). The clinical supervision of the intensive care unit based on restorative function is supportive and gives nurses the opportunity to demonstrate and share their experiences and sense of professional identity as well as interacting with doctors and being independent at work. This leads to quality of care and work satisfaction (Lindahl & Norberg, 2002). This is consistent with previous research that found that clinical supervision applying the restorative function caused nurses who were supervisees to have a good relationship with each other and were satisfied with their work (Tangwongkit et al., 2020; Phanjungharn & Juntachum, 2022).

These three factors of clinical supervision are consistent with Hawkins and Shohet’s (2012) supervision model based on Proctor’s model of clinical supervision. Daily supervision aimed to allow nurses to follow current nursing guidelines and standards both physically and mentally. Adverse events were discussed in planning care and prevention so that the supervisees were confident. This may take a short time before work. Clinical supervision is the opportunity to become increasingly reflective of practice, and to learn from one’s own experience, and the experience of another qualifies clinical supervision as a uniquely formative process (Proctor, 2010). And can also improve the interpersonal relationship cycle (PIR-C) toward nurses’ performance in improving the quality of nursing care documentation. (Yuswanto et al., 2018).