Qualitative Study of Supervisor Feedback on Nurse Managers ’ Reflective Journals

Citation: Kuraoka Y (2018) Qualitative Study of Supervisor Feedback on Nurse Managers’ Reflective Journals. Int Arch Nurs Health Care 4:107. doi.org/10.23937/2469-5823/15100107 Accepted: November 15, 2018: Published: November 17, 2018 Copyright: © 2018 Kuraoka Y. 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 author and source are credited.


Introduction
Front-line nurse manager responsibilities are extensive.Nurse managers are torn between the demands of clinical nurses, physicians, patients, and administration, and are required to demonstrate a combination of clinical skill, leadership ability, and managerial knowledge [1].However, many hospitals have poorly designed nurse manager orientation and professional development programs, or none at all [2].Therefore, nurse managers in the early years of supervisory roles often experience difficulty.A previous study found many firstline nurse managers leave their posts due to a lack of support from and the relationship with the head of their department, indicating they need opportunities for development and support from their supervisors [3].
Feedback is fundamental to the learning process.Giving effective feedback to learners is important to help them acquire new knowledge and skills, especially in light of the shift toward competency-based education [4].A systematic review of the literature on feedback for learners in medical education identified feedback as an important means of improving learner performance, as evidenced by the number of articles outlining recommendations for feedback approaches [5].In addition, a previous study of home nurses indicated that the qual-

Abstract
Objectives: The present study aimed to clarify supervisor feedback on the reflective journals of nurse managers in the early years of supervisory role.
Methods: A total of 63 nurse managers participated in an experiential learning-based program that included writing entries in a reflective journal and supervisor feedback.The Experiential Learning Inventory on the Job (ELI) was administered before and after the program.Overall, 10 nurse managers showed apparent changes in their Experiential Learning Inventory scores after completing the program.We qualitatively analyzed the data from 41 reflective journal entries written by these 10 nurses along with the written feedback from their supervisors and subjected the data to descriptive analysis.

Results:
The analysis yielded the following seven themes: "suggestions on how to describe the situation", "questions to clarify important information", "positive feedback on the nurse manager's thoughts and actions", "analyzing circumstances from the supervisor's viewpoint", "clarifying learning points for the nurse manager", "demonstrating actions the nurse manager should take" and "suggestions on how to develop learning points from experience".

Discussion:
In this study, we provided specific contents of supervisor feedback provided to 10 nurse managers who showed apparent changes in their ELI scores after completing an experiential learning-based program to foster competence among nurse managers.We believe the feedback provided by the supervisors in this study might promote experiential learning among nurse managers.

Limitations:
Because there were only 10 study participants and all had apparent changes in their ELI scores after completing the experiential learning-based program, caution should be exercised in generalizing the results of this study to other groups.To confirm the present results, in the future, it is necessary to investigate supervisor feedback in different subjects, such as nurse managers who did not show changes in their ELI scores after completing the program.
ity of feedback was related to lower levels of turnover intention and this relationship was fully mediated by home nurses' self-efficacy [6].Furthermore, some previous studies have clarified how supervisors or peers should provide feedback.Video feedback with reflection and interactive analysis is an untapped resource for nurse leaders and aspiring nurse leaders in their development of effective leadership skills [7].Participants using peer-to-peer shadowing as a technique for the development of mid-level nurse managers in clinical leadership found that balancing the act of stepping in and taking action or just observing and giving or withholding feedback are important practices that are difficult to develop [8].However, specific, concrete feedback was not found to affect the development of nurse managers.
In a previous study, we developed an experiential learning-based program to foster competence among nurse managers in the early years of supervisory roles that included writing reflective journal entries describing experiential learning and reflections for 4 months, as well as reflective sessions in which a supervisor provides feedback on each reflective journal entry [9].We found that this program promoted experiential learning and improved competence among nurse managers.Furthermore, we clarified the contents of experiential learning from the reflective journals of 10 nurse managers who participated in the program and observed apparent changes in the Experiential Learning Inventory on the Job (ELI) after completing the program [10].In this study, apparent changes were defined as a clear increase in the mean ELI score after completing the program.However, we did not investigate the contents of feedback from supervisors on the reflective journals of the nurse managers.

Objectives
The purpose of this study was to clarify supervisor feedback on the reflective journals of 10 nurse managers in the early years of a supervisory role who participated in an experiential learning-based program to foster competence among nurse managers and to investigate apparent changes in the ELI after completing the program.

Design
A descriptive qualitative design was used in this study.

Intervention program
The program included an introduction to experiential learning, participants writing reflective journal entries describing their experiential learning and reflections for 4 months, and participants holding reflective sessions with their supervisor to receive feedback on each re-flective journal entry [9].We asked nurse managers to write in their reflective journal after they struggled with a challenging task and to continue writing about once a month for 4 months.Instructions were provided asking the participants to: 1) Describe what happened, 2) Reflect on the strengths and weaknesses of their behavior, 3) Describe what they learned about nursing management from the experience, and 4) Describe any skills or behaviors they learned that could be applied in the future.For each reflective journal entry, the nurse manager attended a reflective session with their supervisor to discuss the experience and each of the four elements of the journal entry listed above.The supervisor then provided written feedback to help the nurse manager reflect further and improve their experiential learning [9].We were wholly responsible for conducting the program.

Participants and setting
In total, 63 nurse managers participated in the 4-month experiential learning-based program, which included completing the ELI before and upon completion of the program.The ELI, which was developed by Kimura [11], was thought to be an effective method of evaluating the frequency of experiential learning.The ELI consists of four factors (concrete experience, reflective observation, abstract conceptualization and active experimentation) based on Kolb's [12] Experiential Learning Theory.In the present study, we qualitatively analyzed data from the 41 reflective journal entries and supervisor feedback of the 10 nurse managers who showed apparent changes in ELI scores after completing the program.The data were also subjected to descriptive analysis.The 10 participants were employed at eight acute care hospitals in the greater Tokyo area of Japan.

Procedures
The development and evaluation of the experiential learning-based program are described elsewhere [9].Briefly, the directors of nursing of the participating hospitals provided consent to cooperate in this program and participants were recruited through convenience sampling.All nurse managers in the first 3 years of a supervisory role at the participating hospitals were given a document introducing the study, describing the incentive of 1000 Japanese yen for each nurse manager and supervisor, and a form requesting their participation.The nurse managers who agreed to participate in the study selected one of their supervisors and asked them to participate in the study.The supervisors were also informed in writing about the study purpose, methods and incentive.If their supervisor agreed to participate, the nurse manager returned the completed request to participate form to us by mail.We then informed the nurse managers and their supervisors, both verbally and in writing at their hospitals, about the study purpose, the right to withdraw from the study without penalty, • Page 3 of 7 • Kuraoka.Int Arch Nurs Health Care 2018, 4:107 we analyzed the relationship between supervisor feedback and each of the four elements of nurse managers' reflective journal entries.

Ethical considerations
This study was conducted after obtaining approval from the ethics committee for Epidemiological Studies at St. Luke's International University, Tokyo, Japan (approval no.15-082).In accordance with the Declaration of Helsinki, all nurse managers and supervisors were informed in writing about the study purpose, methods, protection of anonymity, that participation was voluntary, and that the information collected would be used solely for this study.Written informed consent was obtained from all participants prior to the start of the study.

Results
The demographic characteristics of the participants are presented in Table 1.The analysis yielded seven main themes: Theme 1: "suggestions on how to describe the situation", Theme 2: "questions to clarify important information", Theme 3: "positive feedback on the nurse manager's thoughts and actions", Theme 4: "analyzing circumstances from the supervisor's viewpoint", Theme 5: "clarifying learning points for the nurse manager", Theme 6: "demonstrating actions the nurse manager should take", and Theme 7: "suggestions on how to develop learning points from experience" (Table 2).Furthermore, we investigated the relationship between supervisor feedback and each of the four elements of nurse managers' reflective journal entries (Figure 1).All of the themes and subthemes are described in Table 2, but in the text below we focus on only one subtheme for each main theme.

Theme 1: Suggestions on how to describe the situation
The supervisors read the nurse managers' reflective journal entries and provided positive feedback if they believed the nurse manager fully described their situation, such as by clearly describing what happened and how the nurse manager or other people felt and recognized the situation.On the other hand, if the nurse managers' descriptions were unclear, the supervisors provided advice on how to describe the situation more concretely.

Subtheme 1: Demonstrating how to concretely describe the situation
If the nurse managers' descriptions were unclear, supervisors provided a framework to describe the situation or requested that nurse managers revise the details of the situation.
"…I think the problem that occurred on your ward was an ethical problem, but I cannot fully understand that situation based on your description.So, I recom-the protection of anonymity and confidentiality, and the safety of personal data.Written consent was then obtained from the nurse managers and supervisors who agreed to participate and a withdrawal form was provided to each pair.Data were collected between February and August of 2016.

Data analysis
The data for each of the four elements of nurse managers' reflective journal entries were subjected to inductive thematic analysis with reference to the qualitative analysis methodology by Kayama [13].Kayama indicated the following three steps: 1) Read and reread the word record and then identify codes from phrases and sentences, 2) Collate these codes into subthemes, and 3) Merge the subthemes into themes.Following Kayama's [13] method, the author read and reread the feedback provided by supervisors, then identified codes from phrases and sentences, collated these codes into subthemes and then merged them into themes.The author and another researcher openly discussed the feedback contents until consensus on the final set of subthemes and themes was reached.Finally,  well as the actions of the people concerned before the situation happened to clarify the important information.

Subtheme 1: Questions about the background of the situation
Supervisors asked nurse managers for more information about the background of the situation, especially the actions of patients, subordinates, and medical staff that the nurse managers described.mend that you describe the situation again using Johnson's four-step ethical division method."(Supervisor G).

Theme 2: Questions to clarify important information
If the nurse managers had not fully described the situation in their reflective journal entries, the supervisors asked questions about the background of the situation, the judgments and actions of the nurse managers, as   Nurse manager D working in the ambulatory department described a situation in which herself and the physician decided to introduce dialysis to a patient who had severe dementia after considering his overall physical condition.However, the patient became disorderly and dialysis could not be performed.The patient then left the nephrology ward and the nurse manager on that ward was angry and complained by saying "Why did you decide to introduce dialysis for that patient?Did you consider his dementia status?I don't believe that patient can receive dialysis".She thought that she did not provide enough information and must collaborate with the nephrology ward nurse manager after this episode.
The supervisor provided the following feedback: "…I think the problem that occurred on your ward was an ethical problem, not a problem concerning collaboration.First you should consider the quality of life of the patient, and then form different opinions of the patient, family, and physician that may cause friction.And you should create a decision making system for patients after this episode" (Supervisor D).

Theme 5: Clarifying learning points for the nurse manager
Supervisors asked nurse managers to develop their thoughts and verbalized or conceptualized learning points for nurse managers when the descriptions in their reflective journals were abstract.

Subtheme 1: Putting learning points into concrete words
If nurse managers could not clearly describe the learning points of a situation, supervisors promoted the use of concrete words to clarify learning points through experience.
Nurse manager D described a disaster prevention meeting attended by nurses, a physician, and clinical engineers.At first, she intended to leave the role of chairing the meeting to a subordinate; however, since all of the attendees were participating in the meeting for the first time, she decided to chair the meeting herself.She kept asking questions throughout the meeting and the subordinate could not participate.After the meeting, the subordinate told her "I could not ask questions that I prepared beforehand during the meeting…" She thought that she must allow the subordinate to chair the meeting next time.
The supervisor provided the following feedback: "…I think you should leave the role to a subordinate because it can be a successful experience.You should clarify the meaning of "allow" concretely.When and what do you allow subordinates to do?" (Supervisor D).
Nurse manager E described a situation in which a cancer patient who was informed that his cancer was terminal left the hospital without permission.The patient hoped to gain a second opinion from a physician at another hospital and he did not want to wait for a second opinion at the initial hospital.
The supervisor provided the following feedback: "…In this situation, did any nurses in your ward attend the meeting in which the patient and physician discussed a second opinion before the patient left the hospital?How did the physician and nurse share information about a second opinion for this patient?"(Supervisor E).

Theme 3: Positive feedback on the nurse manager's thoughts and actions
If supervisors recognized that the thoughts and actions of the nurse managers were sufficient for that situation after reading the reflective journal entry, they gave positive feedback to the nurse managers.

Subtheme 1: Positive feedback on the nurse manger's actions
The supervisors provided positive feedback to nurse managers if they recognized the effects or suitability of a nurse manager's actions in that situation.
Nurse manager I working in the ambulatory department described a situation in which she had begun to improve management of unperformed tasks triggered by the vacancy of an assistant nurse.She was able to recognize the problem and change how patient dressing gowns for checkups or treatment are prepared in an efficient method.
The supervisor provided the following feedback: "…I think you showed improvement because you struggled with the vacancy of an assistant nurse but were successful in managing the tasks that needed to be performed.And I think you acted appropriately in getting the opinion of the assistant nurse manager and the new assistant nurse who were also involved in this problem before you consulted the physician manager."(Supervisor I).

Theme 4: Analyzing circumstances from the supervisor's viewpoint
Supervisors read the nurse managers' descriptions to comprehensively grasp the situation.If nurse managers seemed confused and could not focus on the important points, the supervisors analyzed the circumstances that the nurse managers described from their own viewpoint and demonstrated the important points for the situation.Supervisors demonstrated concrete actions for nurse managers to overcome problems or better manage situations.Supervisors demonstrated how to support patients and families who have difficulties and complexities or how to help subordinates develop professionally in cases where nurse managers faced actual problems.

Subtheme 1: Demonstrating how to get cooperation from others
Supervisors demonstrated how to get cooperation from supervisors, physicians, medical social workers, and people in other departments who might be disadvantaged because of a nurse manager's actions.
Nurse manager I in the radiation outpatient department described organizational restructuring at her hospital.She stated that she recognized a problem related to nursing care in the interventional radiology section and suggested moving interventional radiology from the radiation outpatient department to the operation room.She thought this change improved patient care and reduced the physical and mental load on nurses in the radiation outpatient department.
The supervisor provided the following feedback: "…You succeed in organizational restructuring.However, you did not consider the disadvantages for other departments.You should think about not only the advantages for your department but also how it could affect other departments.I think it is important to hear the opinions of other people who may be disadvantaged by such changes.That way, you will get cooperation from others smoothly".(Supervisor I).

Theme 7: Suggestions on how to develop learning points from experience
Supervisors suggested that nurse managers should apply the learning points about nursing management drawn from previous experiences to similar situations, patients, and subordinates in the future.
If nurse managers' journal entries described situations in which they applied past learning points to another situation, the supervisors confirmed the learning points.

Subtheme 1: Suggesting other situations in which learning points can be applied
Supervisors provided concrete examples of other situations in which nurse managers might be able to apply learning points gained through previous experiences.
Nurse manager H described a situation in which a new nurse said to her, "I feel stressed about work.I cannot sleep.I am afraid of working with nurse S…" The nurse manager told nurse S about the conversation with the new nurse and suggested nurse S change her teach-ing style so that the new nurse and nurse S could work together.
The supervisor provided the following feedback: "…There are three new nurses besides this new nurse in your ward.I think you learned it is important to manage the stress of new nurses through this experience.I recommend that you turn your eyes towards the other new nurses and gather information about their stress levels at work".(Supervisor H).

Discussion
In this study, we provided concrete contents of supervisor feedback provided to 10 nurse managers who showed apparent changes in their ELI scores after completing an experiential learning-based program to foster competence among nurse managers.We believe the feedback provided by the supervisors in this study might promote experiential learning among nurse managers.
A previous study [14] on business administrators who showed improved performance indicated the following five steps in providing successful feedback: 1) Secure confidence, 2) Indicate facts like a mirror, 3) Convince the person of their own problem actions, 4) Support reflection, and 5) Convey what is expected.Furthermore, Nakahara [14] indicated that supporting reflection is important in helping employees explain their situation.In our study, supervisors provided nurse managers with suggestions on how to describe their situation in detail and asked for clarifications on important information.Nurse managers in the early years of a supervisory role have difficulty describing challenging situations clearly; therefore, we believe feedback from supervisors helped nurse managers reflect more deeply and describe their experiences in more detail.We believe two themes identified in this study, Theme 1: "suggestions on how to describe the situation" and Theme 2: "questions to clarify important information", were types of feedback that were effective in supporting reflection among nurse managers.
The supervisors in the present study analyzed the situations the nurse managers described in their reflective journals and shared their viewpoint to clarify learning points for the nurse manager.In order to learn from experience, nurse managers must analyze the circumstances of each situation and conceptualize the learning points through their experience.However, in this study it was difficult for nurse managers in the early years of a supervisory role to analyze and conceptualize.Therefore, supervisors provided feedback to nurse managers.A previous study indicated nurse managers in the first 3 years of a supervisory role had weak cognitive competency, analytical thinking, and conceptual thinking [15].The results of the present study support the findings of the previous study, and we believe nurse managers should learn from their experiences not through self-reflection but through discussion with others.Supervi-sors have a different viewpoint from nurse managers and can help support the conceptualization of learning points in nurse managers.
In our study, supervisors demonstrated actions that nurse managers should take and suggested ways for nurse managers to learn from experience.Sadler [16] defined feedback as information given to the student about the quality of their performance (knowledge of results) and stated that improvement can occur if the teacher provides detailed remedial advice and the student follows it through.The feedback in Theme 6: "demonstrating actions the nurse manager should take" and Theme 7: "suggestions on how to develop learning points from experience" identified in the present study correspond to providing detailed remedial advice.Therefore, the results of our study support Sadler's [16] findings.We believe that it is important for nurse managers in the early years of a supervisory role to receive concrete advice about their practice from their supervisors.
Our study has implications for the development of nursing management.We clarified concrete contents of feedback from supervisors that previous studies have not identified.In our study, supervisors read the nurse managers' reflective journals and had a reflective session with the nurse and provided written feedback for each entry.In other words, the supervisor provided both written and verbal feedback.We believe it is important for the development of nurse managers that supervisors observe the practice of nurse managers and provide written and verbal feedback following the seven themes identified in the present study.This is because nurse managers in the early years of a supervisory role are particularly in need of support from their supervisors to learn from experience.
The present study has important limitations.Because there were only 10 study participants and all had apparent changes in their ELI scores after completing the experiential learning-based program, caution should be exercised in generalizing the results of this study to other groups.To confirm the present results, in the future, it is necessary to investigate supervisor feedback in different subjects, such as nurse managers who did not show changes in their ELI scores after completing the program.

3 .
Nurse manager's reflective journal entry Feedback from supervisor 1. Description of what happened 2. Reflect on the strengths and weaknesses of own behavior Description of what I learned about nursing management from the experience • Suggestions on how to describe the situation • Questions to clarify important information • Positive feedback on the nurse manager's thoughts and actions • Demonstrating actions the nurse manager should take • Positive feedback on the nurse manager's thoughts and actions • Analyzing circumstances form the supervisor's view point • Clarifying learning points for the nurse manager • Demonstrating actions the nurse manager should take • Clarifying learning points for the nurse manager • Demonstrating actions the nurse manager should take care • Suggestions on how to develop learning points from experience 4. Description of any skills or behaviors I learned that could be applied in the future • Suggestions on how to develop learning points from experience

Figure 1 :
Figure 1: Relationship between supervisor feedback and each of the four elements of nurse managers' reflective journal entries.

Subtheme 1 :Theme 6 :
Demonstrating important points for the situation If nurse managers could not focus on the import-• Page 6 of 7 • Kuraoka.Int Arch Nurs Health Care 2018, 4:107 Demonstrating actions the nurse manager should take

Table 1 :
Characteristics of nurse managers and supervisors.

Table 2 :
Themes and subthemes.Suggestions on how to describe the situation Demonstrating how to concretely describe the situation Positive feedback for clear descriptions about the situation 2. Questions to clarify important information Questions about the background of the situation Questions about actions of the people concerned before the situation happened Questions about the nurse manager's judgment and actions 3. Positive feedback on the nurse manager's thoughts and actions