Multiprofessional clinical supervision: challenges for mental health nurses.

Recent reform and developments in mental health care provision have increasingly espoused the value of multiprofessional teamwork in order to ensure that clients are offered co-ordinated packages of care that draw on the full range of appropriate services available (DoH 1999a; DoH 2000). Supervision in some form is seen as a key part of all professional practice to provide support to practitioners, enhance ongoing learning, and, to a greater or lesser degree, offer some protection to the public (Brown & Bourne 1996, UKCC 1996). Clinical supervision has gained increasing momentum within the nursing profession, but to a large extent this has been within a uni-professional framework -- nurses supervising other nurses. This paper seeks to explore the ways in which multiprofessional working and clinical supervision interlink, and whether supervision across professional boundaries might be desirable, possible, and/or justifiable. Whilst our own view is that multiprofessional supervision is both possible and desirable, we seek to open up a debate, from our perspective as mental health nurses, about some of the issues related to the concept. Our motivation to explore this topic area emanates from our experiences as supervisors to colleagues within multiprofessional teams, as well as the experiences of those attending supervisor training courses. Following a brief overview of the development of clinical supervision in mental health care and recent policy guidelines, some models of clinical supervision are reviewed in terms of their suitability and applicability for multiprofessional working.

Parallel process in clinical supervision: enhancing learning and providing support.

The introduction of clinical supervision in nursing is gaining momentum and is proposed as having numerous benefits for nurses, organizations, and ultimately patient care. The necessity for such supervision has arisen partly from a fundamental shift in the nature and definition of nursing work. The emphasis on individualized, holistic care has led to a change in role from one characterized by professional distance to one in which interpersonal involvement is seen as central. Such a shift, though seen as positive, may lead to increased vulnerability as nurses negotiate the blurred boundaries between the personal and the professional in their relationships with patients. Such boundary negotiation is a legitimate focus for learning and support in clinical supervision. However, as with many aspects of nursing, the subtle processes involved in relationship development are often hidden from consciousness, thus missing potential learning opportunities. One way that such hidden aspects of practice may be explored in clinical supervision is through attendance to the way that such processes are parallelled in the supervisory relationship. Drawing on theory and practice from the fields of counselling and mental health nursing, this paper explores the nature of 'parallelling' in clinical supervision. The implications for clinical supervision in nursing more generally are examined in relation to enhancing learning and providing support for supervisees and supervisors.

Programmed cell death during metamorphosis in the blow-fly Calliphora vomitoria.

During metamorphosis, the salivary glands of the blow-fly undergo programmed cell death. Data is presented indicating that this programmed cell death does not in many respects emulate classical apoptosis. The cells are seen to vacuolate and swell rather than condense and shrink. There appears to be a transient enhancement in autophagy and an increase in acid phosphatase activity. This is followed by the characteristic appearance of ribosomal and extracisternal sources of the enzyme leading to autolysis. There appears to be no lysosomal leakage of acid phosphatase. As in apoptosis, the mitochondria persist until the cell fragments. The nucleus, however, does not show the distinct chromatin margination and blebbing that is typical of apoptosis. These changes are compared with necrotic changes induced by experimental anoxia. Overall the results show that a programmed cell death distinct from classical apoptosis is taking place.

Cell death in the salivary glands of metamorphosing Calliphora vomitoria.

The salivary gland cells of Calliphora vomitoria larvae initiate and complete their own destruction in a programmed manner at the onset of metamorphosis. On entering the post-feeding period the larvae come to rest and the polytene salivary gland cells show a significant increase in DNA synthesis followed closely by a surge of mRNA synthesis accompanied by increasing protein production. During this prelude to cell death the new mRNA gives rise to at least 10 new proteins. The first new proteins having a MWt between 30 and 100kD appear by day 8 of the life-cycle and a number persist until the advent of cell death on day 9. Other new proteins appear in a cascade of production during day 8 and in vitro translation of mRNA produced at this time shows a new 55kD protein appearing before cell destruction. Significantly no evidence of DNA degeneration or laddering associated with classical apoptosis was observed, on the contrary considerable DNA synthesis in the form of chromosomal endoduplication or "genomic amplification" was seen; selective gene expression being apparently controlled at translational level. Overall the results strongly suggest a synthetically mediated programmed cell death in the metamorphosing salivary glands of the blow-fly which is distinct from apoptosis.

The use of backscattered electron imaging, X-ray microanalysis and X-ray microscopy in demonstrating physiological cell death.

The cytochemical localization of enzymatic activity by means of backscattered electron imaging (BEI) is reviewed and the application of BEI to changes in acid phosphatase and ATPase distribution during physiological (programmed) cell death in Heliothis midgut is explored. Programmed cell death entails the release of nascent free acid phosphatase as extracisternal hydrolase. This shift can readily be detected by means of the atomic number contrast imparted by BEI of the lead phosphatase reaction product, thus enabling the distribution of dying cells to be mapped. BEI is particularly useful in this context as it allows the examination of bulk specimens at low magnification. Death of cells is also accompanied by a collapse in ATPase activity which shows up as cytochemically negative areas in the X-ray microscope and by means of BEI. Acid phosphatase in normal cells is localized in the apical microvilli and lysosomes. Senescent or dying cells, however, clearly show a basally situated free hydrolase which migrates throughout the cell. Parallel TEM results confirm that this enzyme is ribosomal and extracisternal rather than lysosomal in origin. ATPase activity is largely limited to the apical microvilli, although there is some activity associated with the basal plasma membranes. The apical ATPase, however is partially resistant to ouabain. Young and mature cells are positive although in the latter case some microvilli may be lost as the cells acquire a negative cap or dome. Inhibition by bromotetramizole indicates that apical activity is not to any significant extent contributed to by alkaline phosphatase. Degenerate or dead cells are negative and can be seen as a mozaic of "black patches" among normal cells when imaged by means of BEI or X-ray microscopy.