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The basics of clinical supervision

The concept of clinical supervision is not new, having been well established for many years in a number of disciplines across the healthcare professions, including mental health and midwifery. However, clinicians are often unsure about what it is and how they might implement it for themselves.

In the current climate of increasing financial that suffer, which ultimately impacts upon the quality of care and productivity of staff. Clinical supervision underpins the very essence of good care, and without it clinicians cannot develop their knowledge, skills and abilities. It should enhance existing education and learning programmes rather than replace them, and should not be seen as a quick fix. This article aims to provide the answers to the main questions about clinical supervision, and I would encourage every health care professional to embrace clinical supervision to support their continuing professional development.

There are numerous definitions which help to put clinical supervision into context .

The Department of Health (DH),5,6 in its document Making a Difference, recognised how activities such as clinical supervision needed to be developed, strengthened and integrated into the wider clinical governance programme, with clear links to annual appraisal and personal development planning. Clinical supervision should not be seen in isolation; it is an essential element of clinical governance and a journey of exploration and discovery which embodies professional and personal development, with the overall aim of enhancing clinical and professional practice. It enables practitioners to develop their skills and knowledge by actively reflecting on their everyday practice. It enables them to problem-solve rather than see challenges to practice as barriers, restricting creativity and innovation. More importantly it gets them talking about their practice, something there is often little time to do.

Professional regulatory bodies support clinical supervision in their respective codes of conduct, in the belief that clinical supervision is necessary if practitioners are to develop their practice in the best interests of patients. Clinical supervision also reflects national guidance from professional regulators who recognise the importance of supervision and peer support for all health care providers.7-10 With the emphasis on integration and collaboration within healthcare, clinical supervision provides an excellent forum for this to be developed, and should be encouraged to enable staff to engage in this.

More recently the Care Quality Commission (CQC)11 outlined clearly what providers should do to comply with the section 20 regulations of the Health and Social Care Act. Outcome 14 is one of the core 16 standards on quality and safety and makes specific reference to supporting front-line staff by ensuring they receive appropriate training, education, professional development, supervision and appraisal; all of which are inextricably linked to clinical governance frameworks. Everyone involved in delivering care could benefit from clinical supervision.

Over the years, high-profile cases in the media have raised the need for practitioners to be more transparent, and while clinical supervision might not have prevented some of these significant incidents, it may well have provided a forum for staff to discuss concerns and issues they may have had before reaching crisis point. Examples include Beverley Allit, Harold Shipman, Victoria Climbié and more recently Baby P, Bristol Royal Infirmary, Mid Staffordshire and the Winterbourne scandal. While the debate continues about professional regulation for healthcare support workers, it seems logical to look at other ways of minimising risk and promoting high standards of care for all healthcare professionals.

The term clinical supervision continues to be challenged as it can be viewed as a mechanism for checking up or finding fault, and can be misinterpreted by managers as a tool for performance monitoring. Clinical supervision is not managerially led and is not the same as preceptorship or mentorship, which are different concepts required for professionals at different times in their careers. It is also not counselling, and a skilled supervisor will be able to acknowledge when boundaries become blurred and address these accordingly.

The main functions of clinical supervision can be categorised utilising Proctors' model12,13 as follows:

  • Normative: reviewing, maintaining and developing standards of care in relation to safety, ethics and quality practice.
  • Formative: developing professional knowledge and skills and embrace the concept of reflection to apply theory to practice.
  • Restorative: the supportive element focusing on self-awareness and self-development.

These categories can be used as a useful framework to identify key aspects of clinical supervision and clarify its aims and objectives. Those under supervision can also use these categories to consider relevant topics to bring to the supervision. Box 2 provides examples of suitable topics to bring to sessions that may help, particularly when starting out, but the list is endless and in reality once staff get started there are no shortage of topics to discuss. 

Clinical supervision has a number of anticipated benefits for staff, and the organisation supporting their practice. Evidence suggests that staff having clinical supervision will:

  • Feel supported.
  • Experience less stress, burnout and sickness/absence.
  • Develop personally and professionally.
  • Be less inclined to leave the profession.
  • See increased confidence levels.
  • Feel less isolated.
  • Develop clinical competence and knowledge.14

Alongside these benefits for the individuals, involved organisations will also benefit by:

  • Improved quality of patient care.
  • Improved communication amongst professional groups, particularly where clinical supervision groups are multi-professional.
  • A means of developing nursing practice in order to improve the quality of patient care.
  • Dissemination of good practice, shared learning.
  • Reduced turnover of staff/sickness.
  • Providing a tool for maintaining, monitoring and developing good practice.
  • Encouraging innovation, motivation and job satisfaction. 

The Manchester Clinical Supervision Scale (MCCS) measures the effectiveness of clinical supervision from the perspective of the person being supervised using a quantitative methodology, and has been used effectively to demonstrate specific factors influencing the success of clinical supervision.15 However, further research is necessary to really look at the relationship between clinical supervision and improved clinical outcomes, which can be challenging when trying to identify the impact upon practice. It could be argued that other structured organisational support mechanisms are just as effective, so organisations need to be convinced that clinical supervision will improve efficiency and effectiveness, particularly within the current constraints within NHS organisations.13

Often healthcare professionals are sent on clinical supervision courses without really knowing what to expect or any understanding of the concept. This can cause anxiety and confusion, so it is essential that myths and misconceptions are challenged from the start. There is a wealth of literature on the topic and wider reading around the subject is recommended to really fully understand what is involved, and ultimately to be able to engage with clinical supervision effectively. 

Deciding which type of clinical supervision is for you needs to be given consideration. Approaches include individual one-to-one and group supervision, which might be within the same discipline or multi-professional - but whichever approach is used, getting the supervisory relationship right is paramount and is key to the success of clinical supervision. 

Within all organisations there will be staff with the skills, knowledge and attitude to undertake the role of supervisors, and it is essential that they are enabled to take on this role while also receiving clinical supervision themselves. There is a wide range of literature outlining the required competencies to be a supervisor, and engagement in the appraisal system will enable managers to identify staff with the required skills in order that staff can take on these roles.12,13

The logistics of planning clinical supervision can be challenging and include identifying protected time, finding a suitable venue free from interruptions, training and support for supervisors, setting up contracts and audit and evaluation. Merely attending training will not equip everyone with the skills and knowledge to take clinical supervision forward, and so training and analysis needs to be ongoing to address additional requirements such as facilitation skills for supervisors or developing reflective practice skills for both supervises and supervisors.

Reflection is a key element of clinical supervision and there are numerous models to adopt to support the process which include Gibbs,16 Johns,17 Kolb,18 and Rolfe et al.19 A model provides a structured framework through the process of reflection to enable the practitioner to demonstrate their development and learn from experience. Healthcare professionals need to embrace reflection and critically analyse situations and experiences to constantly improve and develop practice. The focus should not just be on negative situations, but should also embrace positive experiences so that this learning can be shared across professions.20 Clinical supervision provides the perfect platform for staff to actively engage in reflection and develop the skills required to take this forward into their everyday practice.

Getting started

Policies and guidelines are a legal requirement and underpin good practice. They are also required to fulfil clinical governance requirements and ensure resources are used effectively. Attendance will be monitored where Trusts are investing in this activity for their staff and where staff identify difficulty in accessing sessions this should be addressed. You do not have to provide in-depth details of discussion, but Trusts may request information from supervisors on key themes, to provide data on future training needs and identify gaps in knowledge and skills.

Things to consider when starting out include:

  • Your local policy provides a framework that can be used to decide what works best for you.
  • Roles and responsibilities of supervisors and supervisees.
  • Identify appropriate supervisors - it shouldn't be your line manager or a friend.
  • Format, eg. individual, group, etc.
  • Frequency.
  • Venue.
  • Time/duration.
  • How often you will review and evaluate? 

Legal and ethical issues

When staff begin to engage in clinical supervision, their main concerns and anxieties seem to focus on key legal and ethical issues, namely:

  • Confidentiality.
  • Record-keeping and documentation.
  • Accountability.

This seems surprising when these areas are fundamental to everyday practice, and it is important that those involved in clinical supervision discuss and clarify these aspects from the start. Professional codes of conduct provide a sound basis to start, as these principles will be clearly outlined in these documents. For example the Nursing and Midwifery Council (NMC) code of conduct21 makes clear reference to all three elements, and as such can form the basis for discussion in clinical supervision sessions so staff can really consider what these mean in practice to ensure safe, high quality care. Local policy will identify what records needs to be kept, and of course as nurses you will keep records of such activity in your personal and professional portfolio for prep requirements.22 It is often surprising that once staff start to talk about these issues and applying their principles to practice, many of their concerns are misplaced and greater understanding and confidence develops.

In December 2012, the Chief Nursing Officer launched a three-year strategy for nursing, Compassion in Practice, identifying the six Cs of good quality care (care, compassion, competence, communication, courage and commitment) and six priority action areas. Action area five supports the need to develop models of good practice from areas such as midwifery and mental health in embedding clinical supervision for other professional groups, once again recognising the value of clinical supervision for all front-line staff.23

Clinical supervision is an important means of supporting your continuing professional development and embracing reflective practice. Given the current climate of constant change and challenging times within healthcare it has never been more essential for frontline staff.

References

1. Butterworth T, Faugier J. Clinical Supervision and Mentorship in Nursing. London: Chapman & Hall; 1992. 

2. Kavanagh DJ, Spence SH, Wilson J, Crow N. Achieving Effective Supervision. Drugs and Alcohol Review 2002;21:247-52.

3. Wright SG. Changing Nursing Practice 2nd Edition. London: Arnold; 1998.

4. DH. A Vision for the Future. The nursing, midwifery and health visiting contribution to health and health care. London: HMSO; 1993.

5. DH. Making a Difference. Clinical Supervision in Primary care. 2000. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4061520.pdf 

6. DH. Making a Difference. London: DH; 1999.

7. NMC. Clinical Supervision for Registered Nurses. London: NMC; 2008. Available at: www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Clinical-sup...

8. HPC. Your guide to standards for continuing professional development. 2011. Available at: www.hpc-uk.org/assets/documents/10003858Your_guide_to_our_standards_for_...

9. RCSLT. Royal College of Speech and Language Therapists. Royal College of Speech and Language Therapists Professional Standards. 2009. Available at: www.rcslt.org/resources.

10. SCR. Society & College of Radiographers. Clinical Supervision Framework. 2003. Available at: www.tinyurl.com/clinical-supervision.

11. Care Quality Commission. Guidance about compliance - Essential Standards of Quality & Safety. London: CQC; 2010. Available at: www.cqc.or.uk.

12. Cassedy P. First Steps in Clinical Supervision. Berkshire: Open University Press; 2010. 

13. Bond M, Holland S. Skills of Clinical Supervision for Nurses. 2nd Edition. Berkshire: Open University Press; 2010. 

14. Sloan G. Clinical Supervision; beginning the supervisory relationship. British Journal of Nursing 2005;14(17):918-23.

15. Edwards D, Cooper l, Burnard P, Hanningan B, Adams J, Fothergill A, Coyle D. Factors Influencing the Effectiveness of Clinical Supervision. Journal of Psychiatric and Mental Health Nursing 2005;12,405-14.

16. Gibbs C. Learning by doing: A guide to teaching and learning methods. Further Education Unit. Oxford: Oxford Polytechnic; 1988.

17. Johns C. Reflection as Empowerment. Nursing Enquiry 1999;6;241-9.

18. Kolb DA. Experiential Learning. New Jersey: Prentice Hall; 1984.

19. Rolfe G, Freshwater D, Jasper M. Critical Reflection in Nursing and the Helping Professions: A User's Guide. Basingstoke: Palgrave Macmillan; 2001.

20. Canham J, Bennett J. Mentorship in community nursing: challenges and opportunities. Oxford: Blackwell Science Ltd; 2002.

21. NMC. The Code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC; 2008. Available at: 

www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf.

22. NMC. The PREP Handbook. London: NMC; 2011.

23. DH. Compassion in Practice. London: DH; 2012. Available at: 

www.commissioningboard.nhs.uk/nursingvision.