Keeping support and clinical supervision on your agenda
evidence and practice    

Free Keeping support and clinical supervision on your agenda

Iain Colthart Research and information officer, NHS Education for Scotland, Edinburgh, Scotland
Kathleen Duffy Head of programme, NHS Education for Scotland, Glasgow, Scotland
Valerie Blair Head of programme, NHS Education for Scotland, Glasgow, Scotland
Lesley Whyte Associate director, NHS Education for Scotland, Edinburgh, Scotland

Support and clinical supervision can benefit staff and service users. Inquiries have highlighted lack of support and clinical supervision as potential contributory factors for adverse care events. For support and clinical supervision to be embedded effectively, leaders and managers must value and promote them in their organisations. This article describes practical steps to support implementation of clinical supervision. By examining the main stages of supervision and preparation, evaluation of process and outcomes, and practical considerations, the article supports healthcare managers to encourage staff engagement and to implement a clinical supervision process.

Nursing Management. doi: 10.7748/nm.2018.e1804

Citation

Colthart I, Duffy K, Blair V et al (2018) Keeping support and clinical supervision on your agenda. Nursing Management. doi: 10.7748/nm.2018.e1804

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

Correspondence

iain.colthart@nes.scot.nhs.uk

Conflict of interest

None declared

Published online: 28 November 2018

Introduction

Following high-profile inquiries of significant adverse care events in the UK, greater emphasis has been placed on how staff are supported in the workplace (Department of Health (DH) 2012, Francis 2013, Andrews and Butler 2014, MacLean 2014, Kirkup 2015). The Winterbourne review (DH 2012) states that supervision should be viewed as a core element of care that helps ensure staff demonstrate their organisations’ values, while McCutcheon et al (2018) highlight that clinical supervision has an internationally recognised potential to improve patient care and safety. However, Smikle (2017) points out that, in the 20 years since influential papers on clinical supervision were first published, there is little evidence it has been applied in the NHS; despite a plethora of policies on supervision from NHS trusts and health boards in England, Scotland and Wales, it does not take place universally and routinely.

The chief nursing officer of Scotland has made a commitment that, by 2030, all nurses, regardless of grade or setting, will receive supervision appropriate to their roles (Chief Nursing Officer Department and Healthier Scotland 2017), while a recent joint statement from Allied Health Professions in Scotland and NHS Education for Scotland (Allied Health Professions in Scotland 2018) states: ‘All [allied health profession] practitioners, irrespective of their level of practice or experience, should have access to, and be prepared to make constructive use of, supervision.’ This statement offers principles and guidance to support supervision for all allied health professionals (AHPs) and AHP healthcare support workers (HCSWs) across health and social care in Scotland, and aligns with guidance already implemented in Northern Ireland (Department of Health, Social Services and Public Safety (DHSSPS) (Northern Ireland) 2014). Meanwhile, a ten-point action plan launched last year by England’s chief nursing officer calls for the establishment of clinical supervision for nurses and HCSWs in general practice (NHS England 2017). Similarly, changes to how the Nursing and Midwifery Council (NMC) regulates midwifery practice has resulted in each of the four UK countries planning and cultivating their own models of employer-led midwifery supervision.

This article describes practical steps and resources (Box 1) that will encourage practitioners and managers to engage in clinical supervision, and thereby help them to feel better supported to deliver safe, effective and person-centred care.

Box 1.

Resources to support clinical supervision

  • NHS Education for Scotland (2017) Maternity Care: Clinical Supervision is a resource comprising four modules to help midwives develop relevant knowledge and skills for participating in clinical supervision

  • NHS Education for Scotland (2018) Clinical Supervision is a resource for all nurses, midwives and allied health professionals. Based on Clinical Supervision for Midwives, it comprises one unit for supervisors and supervisees, and three units for supervisors

Key points

  • Clinical supervision can support healthcare staff to improve patient experience, outcomes and safety

  • Organisational commitment and endorsement through role modelling and clinical supervision policies are crucial components of effective clinical supervision

  • Organisations can help supervisors and supervisees prepare by identifying a suitable model and providing training for supervisors

  • It is important for supervisees to reflect on their practice and plan subjects for discussion ahead of their supervision sessions

  • The clinical supervision process and outcomes must be evaluated continually to identify challenges and what works well

Clinical supervision

Milne (2009) suggests that, since the apprenticeship model has been widespread in healthcare for centuries, it is likely that supervision has been practised since ancient times. Milne reports that it was advocated in nursing after a conference on clinical supervision held in 1925 by the Institute of New York State League of Nurse Education, at Mount Sinai, New York.

According to Helen and Douglas House (2014), clinical supervision was first described in terms of being ‘a systematic tool for improving practice’ in the DH (1993) strategic document, A Vision for the Future. However, in the intervening years supervision has not been implemented equally across the professions. In midwifery, clinical supervision was statutory from the early 1900s until recently; in disciplines such as mental health and child protection, where supervision is mandatory, models are embedded in practice.

There are numerous definitions of clinical supervision (Milne 2007). Lyth (2000) defines it as ‘a support mechanism for practising professionals within which they can share clinical, organisational, developmental and emotional experiences with another professional in a secure, confidential environment in order to enhance knowledge and skills’.

When thinking about what clinical supervision is, it is helpful to consider it alongside similar activities. The nursing literature distinguishes between clinical supervision, mentoring and preceptorship (Fowler 1996, Mills et al 2005, Lennox et al 2008). For example, Mills et al (2005) characterise: clinical supervision as a way of progressing clinical practice through reflection and providing professional guidance and support; mentoring as a way of ensuring career progression, scholarly achievement and personal development; and preceptorship as a way of ensuring skills acquisition and socialisation.

Bush (2005) emphasises the positive aspects of clinical supervision, adding that it is not a management tool or a form of criticism or therapy. Beddoe and Davys (2016) note that supervision can be regarded as a reflective learning process and a means of surveillance. For individuals it can provide a protective mechanism against stress, while for teams and organisations it can improve communication and staff retention (NHS Education for Scotland 2017).

In reporting on clinical supervision practice among general practice teams in Lambeth, London, Ashwood et al (2018) found that supervision helps to ensure nursing and HCSW staff are retained. The broad aims of clinical supervision are improving professional self through lifelong learning, improving professional practice and providing support for individuals (Allied Health Professions in Scotland 2018). Practitioners can also undertake clinical supervision to demonstrate continuing professional development, and it can contribute to evidence for their re-registration and revalidation (Health and Care Professions Council 2011, NMC 2015). Other benefits for staff include personal development, enhanced self-awareness and confidence, and increased job satisfaction (Baylis 2014, Smikle 2017).

Clinical supervision should be an integral part of clinical practice and is typically delivered on a one-to-one basis, in triads or in groups (Sloan and Watson 2002, Pollock et al 2017). It is usually delivered face to face, but can be undertaken remotely. Chilvers and Ramsey (2009) observe that clinical supervision by telephone is effective for lone workers, and those working in remote and rural locations. Video conferencing technology, such as Skype and FaceTime, offers other ways of conducting remote clinical supervision sessions (Ducat and Kumar 2015).

Proctor’s (1986) model identifies three complementary areas in which clinical supervision operates. The first is the formative or educative area, which concentrates on the supervisee’s skills, abilities, knowledge, understanding of client needs and development of self-awareness. The second focuses on managerial issues and professional standards, reflecting the organisation’s goals, strategies, policies and standards. The third addresses the restorative functions of personal support and emotion management.

Some supervision models allow for flexibility in carrying out clinical supervision. For example, Evans and Marcroft (2015) identify a model with six options, namely group-facilitated supervision, reflective logs, clinical specialist supervision, peer supervision, peer review and action learning sets, from which individuals can choose their preferred options. Dawber (2013) explores the use of combinations of open and closed groups for clinical supervision sessions.

Establishing support

Whichever model nurse managers choose, they have a role in embedding clinical supervision in their practice environments. The literature points to a need for formal and informal endorsement by organisations and individuals to enable clinical supervision to take place (Kilminster et al 2007, Gonge and Buus 2016). Formal endorsement may be regulatory and related to clinical governance (Milne et al 2011), while informal endorsement may simply involve encouraging conversations with colleagues (Farber and Hazanov 2014).

Organisations’ attitudes to clinical supervision are equally important. Some organisations or individuals may not support or engage with the practice (Butterworth et al 2008, Allbutt et al 2017). This lack of support may be due to the perception that pressures on budgets and resources prevent changes to practice (White and Winstanley 2009), or that clinical supervision is not ‘legitimate’ clinical work and detracts from service delivery (Dilworth et al 2013).

Organisational and management support is an enabler of clinical supervision. For example, White and Winstanley (2009) describe a training course for mental health nursing staff in which one of the most helpful factors in implementing clinical supervision was support from the nurse unit manager. The authors conclude that, in introducing and embedding clinical supervision, obvious management buy-in is essential (Daly and Muirhead 2015). Having a policy on clinical supervision demonstrates an organisation’s commitment (Allbutt et al 2017). Table 1 outlines some questions to consider when committing to clinical supervision in an organisation.

Table 1.

Establishing support and clinical supervision in an organisation

QuestionTips and resources
Does the organisation have a policy to guide clinical supervision?A clinical supervision policy enables organisations to demonstrate their commitment to it, articulate its purpose and provide a framework for a consistent approach. Examples of organisational clinical supervision policies can be found by searching the internet
What is the best way to deliver support and clinical supervision?Organisations should agree a model – one to one, triad or group session – that best suits the purpose of clinical supervision and the needs of stakeholders. Examples can be found in:

Given the potential advantages of clinical supervision, it is important that managers are aware of the benefits for staff, service users and organisations. Managers’ attitudes to clinical supervision may be shaped by their experiences of it. White and Winstanley (2009) observe that, at an individual level, managers may have reservations about the effect of clinical supervision on organisational culture and their own positions. This may be due to a lack of understanding of the concept (Bush 2005) manifesting through different managerial and clinical expectations of clinical supervision (Cleary et al 2010).

For clinical supervision to function effectively, managers should be aware of the operational challenges it creates and put measures in place that make it easier to embed in practice. Dellefield (2008) identifies inadequate staffing levels and limited resources for staff development as operational barriers, while other authors highlight pressure on time and workload demands (Ducat and Kumar 2015, Martin et al 2015, Beddoe and Davys 2016).

In an evaluation of group supervision in three hospices, Chilvers and Ramsey (2009) demonstrate how solutions to operational challenges can be found with management support. Reasons for non-attendance at supervision sessions included ‘the ward is too busy for me to leave’ and ‘I have not completed my paperwork’. However, it was possible to resolve these challenges by, for example, changing the timing of clinical supervision meetings.

Once nurse managers have articulated their organisations’ commitment to clinical supervision, thought must be given to guidance and preparation of staff undertaking the roles of supervisor and supervisee. Staff can feel ambivalent about, or resistant to, clinical supervision, so it is important for managers to act as role models by participating in clinical supervision themselves, and ensuring that staff appreciate its potential value and are adequately prepared for participation.

Preparing for clinical supervision

Practical tips and some useful resources for supervisors and supervisees are shown in Table 2.

Table 2.

Preparing for support and clinical supervision

QuestionsTips and resources
Preparation as a supervisor:
  • How do I prepare for the role of supervisor?

  • Can I identify training or development needs in relation to my supervisor role?

Reflect on your knowledge, skills and needs as a supervisor:
  • Self-reflection tools for supervisors are available in the Helen and Douglas House (2014) Clinical Supervision Toolkit facilitator self-assessment tool

  • Queensland Health (2009) Clinical Supervision Guidelines for Mental Health Services self-assessment of supervisor competencies

Preparation as a supervisee:
  • Is there available training to enable me to understand and develop my role in the clinical supervision process?

  • What did I do well in my professional practice since the last clinical supervision meeting and are there areas for improvement?

Reflect on your knowledge, skills and needs as a supervisee:
  • Social Care Institute for Excellence (2017) Effective Supervision in a Variety of Settings

  • Queensland Health (2009) Clinical Supervision Guidelines for Mental Health Services self-assessment of supervisor competencies

  • Effective Practitioner and NHS Education for Scotland (2018) Self Assessment will help you work out how effective you are in your practice and your learning needs

  • Keep a diary of experiences from practice

  • Refine your notes from your diary and rank the most important points to discuss during clinical supervision

Supervisors and supervisees preparing to get the most from clinical supervision:
  • Do I value the clinical supervision process?

  • Am I prepared to be open and honest during the clinical supervision session?

For supervisors:
For supervisees:
  • Attend clinical supervision meetings punctually

  • Go well prepared

  • Suggest topics for discussion at the clinical supervision session

  • Queensland Health (2009) Clinical Supervision Guidelines for Mental Health Services self-assessment of supervisor competencies

For supervisors organising and attending a clinical supervision session, consider:
  • Have I checked the room is suitable?

  • Have I minimised interruptions?

  • Do I have hospitality for the supervisee?

For supervisees attending a clinical supervision session, consider:
  • What method of supervision would I like? For example, face to face, video conference, teleconference?

  • How often would I like a supervision session?

  • How long would I like the session to last?

  • Where would I like sessions to take place?

  • Buckinghamshire Health NHS Trust (2014) What Is Clinical Supervision? is a video covering all aspects of one-to-one clinical supervision

  • Think about which type of supervision method is best in each situation

  • Think about the practicalities as well as the process of supervision

Preparation for supervisors

A supervisor’s skill set is one of the most important aspects of a successful clinical supervision arrangement (Morrison 2005, O’Donoghue 2014) so they should reflect on their knowledge, skills and needs (Kilminster et al 2007, Martin et al 2014). Kilminster and Jolly (2000) identify supervisors’ required skills as: teaching, assessment, counselling, appraisal, feedback, careers advice, interpersonal skills, and understanding the concept and purpose of clinical supervision. Supervisors may find a self-assessment tool useful for reviewing their skills and identifying training needs. MacDonald (2002) suggests that experience in clinical roles would also prepare staff to be effective supervisors, although Gonsalvez and Milne (2010) state that this ‘experience begets expertise’ assumption is flawed. The literature points to variations in training undertaken by supervisors to fulfil this role (Pollock et al 2017).

Preparation for supervisees

Clinical supervision is a formalised system of support and development designed to help supervisees improve their practice through self-reflection and problem-solving. Supervisees should therefore foster these attributes in preparation for their part in the process. O’Donoghue (2014) found that supervisees are often concerned about what to take to clinical supervision sessions and, to ensure they are well prepared, record practice issues in their diaries, make notes and add reminders for their next supervision sessions. Nearer to the session they refine these lists before deciding what to present.

Decisions on order of priority can be made by supervisees alone or with their supervisors.

Attitude and commitment

Two vital ingredients of effective clinical supervision are a good attitude and the commitment of both parties (Kilminster at al 2007). Supervisees can demonstrate their commitment by, for example, attending meetings punctually, being well prepared, suggesting topics for discussion and leading sessions (Kilminster et al 2007). In a qualitative review of supervisors’ and supervisees’ experiences of clinical supervision sessions in a social work environment, O’Donoghue (2014) found that supervisors’ preparation involved reviewing records from previous sessions and thinking about forthcoming meetings.

Supervisors and supervisees also need to consider the practicalities of clinical supervision sessions, such as agreeing which model to use, and the venue, time, length and frequency of sessions (Martin et al 2014). Pollock et al (2017) found a variation in the frequency and duration of supervision sessions in the studies they reviewed, while Martin et al (2015) highlight the need to identify optimal session length and frequency. Winstanley and White (2003) suggest that sessions should be about one hour long and take place at least monthly.

Some authors recommend that sessions take place away from the workplace in a quiet location and be free from interruptions so that frank but confidential discussions can take place (Jones 2001, Martin et al 2014). O’Donoghue (2014) highlights that, immediately before each session, supervisors should check the room, minimise the chances of interruptions and provide hospitality.

Undertaking clinical supervision

When staff are ready to undertake clinical supervision, they may require the support of, and role modelling by, their nurse managers to create good supervisory relationships and a safe learning environment. The relationship between supervisor and supervisee is the cornerstone of productive clinical supervision (Kilminster and Jolly 2000, Sloan 2005, Martin et al 2015), yet few studies explore supervisory relationships in depth (Sloan 2005). Most of the literature focuses on supervisees’ views on how supervisors can ensure clinical supervision is productive. For example, if supervisors can create a warm and supportive relationship, provide feedback and guidance about interventions, promote autonomy (Pesut and Williams 1990), and demonstrate understanding (Severinsson and Hallberg 1996), supervisees can be more honest about their practice, identify what they are doing well and explore areas for development and improvement.

How relationships between supervisors and supervisees form is an important factor in how well they operate (Table 3). Cerinus (2005) undertook an action research project to investigate clinical supervision for nurses at a general hospital. In half of the relationships the supervisee knew the supervisor and had chosen them, while in the other half the supervisor was allocated. This had an important bearing on the relationship from the outset.

Table 3.

Undertaking clinical supervision

QuestionsTips and resources
  • Can the supervisee choose the supervisor?

  • Organisational policy should outline the selection of supervisors

  • How should the clinical supervision session be conducted?

  • Which reflective model would be most beneficial for the supervisee?

  • Setting clear guidelines means both parties know what is expected of them and what is required in the supervisory session

  • Examples of guidelines include Howard’s (1997) checklist (Box 2)

  • A model clinical supervision agreement can be accessed at Queensland Health (2009) Clinical Supervision Guidelines for Mental Health Services

  • Information on various reflective models can be found in the first unit of NHS Education for Scotland (2018) Clinical Supervision

  • How should the clinical supervision meeting be recorded?

  • A template that sets out what should be documented should be created and serve as a record of the meeting

  • Examples of recording templates can be found in Allen et al (2010) Professional/Clinical Supervision Handbook for Allied Health Professionals and Queensland Health (2009) Clinical Supervision Guidelines for Mental Health Services

When the two parties knew each other, they found it easier to establish a relationship and feel comfortable, but knowing the other party and feeling comfortable were not the only factors required. Trust and confidentiality also contributed to the development of a productive partnership, and the ability to choose the supervisor played an important role in this. The ability to choose a supervisor can enhance the supervisory relationship, which should improve the supervision (Martin et al 2014).

Sloan (2005) stresses the importance of establishing and nurturing the supervisory relationship, and taking time at the start of sessions to discuss how this will evolve for both parties. Sloan acknowledges that the start of supervisory relationships can be an anxious time, but that these anxieties can be reduced if both parties are open about their expectations and establish how the sessions will run. Use of a checklist (Box 2) sets ground rules for the development of good relationships (Sloan 2005). Reflection is an integral part of clinical supervision and agreeing on which reflective model or models to adopt may prove useful during the development of the supervisory relationship.

Box 2.

Supervisory checklist

  • Purpose of supervision

  • Professional disclosure statement

  • Practical issues

  • Goals

  • Methods and evaluation

  • Accountability and responsibility

  • Confidentiality and documentation

  • Dual relationships

  • Problem resolution

  • Statement of agreement

(Howard 1997)

A good supervisory relationship is essential for creating a safe learning environment in which supervisees can be open about their practice, and potential learning and development needs. Sloan’s (2005) checklist includes an agreement on how sessions are recorded. Cutcliffe (2000) and Sloan (2005) identify documentation as an area that can cause anxiety for supervisors and supervisees because they may be accessed by employers, professional body conduct committees or courts as evidence of poor performance. This anxiety can compromise the effectiveness of supervisory sessions, so setting ground rules for confidentiality, support and the recording of sessions is essential for establishing trust and a safe learning environment.

Documentation

There is no definitive method of recording supervision sessions; it is subject to local policy and agreement between supervisors and supervisees. Cutcliffe (2000) suggests three levels of documentation:

  • Supervisors record minimum data to meet the needs of audit.

  • Supervisees make extensive notes for their learning journals or reflective diaries.

  • Supervisors record important headings or words to be used as reminder.

Cutcliffe (2000) suggests that supervisors record the names of supervisees, and the date and duration of each session, to meet the employer’s requirements for audit, adding that, because supervisees are encouraged to lead clinical supervision sessions, their notes should form the basis of documentation of the content of the session. Similarly, Butterworth et al (1997) found it is common practice for supervisees to be responsible for leading and documenting clinical supervision sessions. Cutcliffe (2000) emphasises that learning needs recorded in a self-reflective diary should be regarded as a development tool, not a list of shortcomings, and suggests that, if supervisors want to take additional notes, these should be brief headings to plan the next session.

Reflection and evaluation

Of all the features of clinical supervision, reflection and evaluation receive the least attention. However, it is important to consider them from the perspectives of supervisees, supervisors and organisations. Not all supervisory relationships work so the outcomes and effectiveness of sessions should be monitored. Local policies should provide guidance on addressing and resolving concerns about supervisory relationships. Sloan (2005) suggests that careful planning and clear expectations at the start, and regular reviews, can reduce the likelihood of problems arising.

The main functions of evaluation for organisations are to assess the effect of clinical supervision on patients, staff experience and care delivery, and to identify workforce learning and development needs (Butterworth et al 2008, White and Winstanley 2010, Tsong and Goodyear 2014, Queensland Health 2016). It is therefore helpful for organisations to audit clinical supervision activity (DHSSPS 2008).

Tools with templates that help supervisor and supervisee reflection and feedback are freely available and might also contribute to organisation audits, while supporting the confidentiality element of clinical supervision. Further information is provided in Table 4.

Table 4.

Evaluating clinical supervision

QuestionsTips and resources
  • How well is clinical supervision working in the organisation?

  • Is the supervisory relationship working for both parties?

  • Allen et al (2010) Professional/lClinical Supervision Handbook for Allied Health Professionals for a sample annual evaluation

  • What topics have been discussed and what has been most helpful?

  • What have I learned about myself?

  • What actions have I taken forward?

  • Has clinical supervision resulted in changes to my practice?

  • Use reflection as part of your appraisal, personal development planning and evidence for revalidation

  • Reflect on your knowledge, skills and needs as a supervisor and identify training or development needs

  • See the self-reflection tools for supervisors and supervisees in Table 2

  • To review the supervision process and sessions see Supervision Outcomes Survey and Evaluation Process within Supervision Inventory available in Queensland Health (2009) Clinical Supervision Guidelines for Mental Health Services

  • How has clinical supervision helped the care I deliver, team working and my personal development?

  • Some of the responses to these questions, where agreed, could be shared anonymously with the organisation as part of annual auditing

Often, organisations demonstrate good practice but do not gather and collate information routinely, so it can be difficult to show the effect of clinical supervision on patients and staff. Similarly, learning needs may emerge to support the role development of supervisors as well as supervisees (Kilminster et al 2007, Martin et al 2014).

Conclusion

Clinical supervision as a means to support healthcare staff in improving patient outcomes and safety is back on the care agenda in the UK. A crucial component of introducing effective clinical supervision is securing an organisation’s endorsement, and nurse mangers have a role in ensuring this message is conveyed to staff. Tangible signs of commitment are organisational clinical supervision policies and managers participating in clinical supervision themselves.

It is important that organisations are committed to supporting supervisors and supervisees to prepare for clinical supervision. This preparation involves identifying a suitable supervision model, ensuring supervisors receive skills development training, helping supervisees to reflect on their practice before each session, and considering practical issues such as the appropriate venue. The relationship between supervisors and supervisees requires a safe environment in which discussions can take place.

The clinical supervision process and outcomes must be evaluated continually so that benefits and difficulties are identified. If an outcome is not achieved, alternative approaches involving, for example, changes to model or supervisor, should be considered. Finally, encouraging and supporting staff to engage in clinical supervision may help managers reduce stress and enhance communication among teams, and improve staff retention.

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