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Clinical supervision: experience within two PCTs

Denise Hadfield
MSc SRN RMN DipCouns(Man)
Teaching Fellow/ Clinical Supervision Consultant
The School of Nursing, Midwifery and Health Visiting
University of Manchester
E:denise.hadfield@man.ac.uk

Contributors:
Margaret D Jones
RGN RM
ASI Specialist Practitioner
Clinical Supervision Project Coordinator
Tameside & Glossop PCT
Cheshire

Rhona Jones
RGN SCM DipFC DipCHD DipDiabetes ASI Specialist Practitioner
Clinical Supervision Project Coordinator
Oldham PCT
Oldham

Many definitions of clinical supervision exist in the literature. However, Wright's description gives an insight into the practice and purpose:(1)

"Supervision is a meeting between two or more people who have a declared interest in examining a piece of work. The work is presented and they will together think about what was happening and why, what was done and said, and how it was handled - could it have been handled better or differently, and if so, how?"

Clinical supervision therefore incorporates the essential activities recommended in the directives received from Butterworth and Faugier,(2) the UKCC(3) and the Department of Health.(4,5) That is, practitioners should engage in regular reflection and critical analysis of their practice and work experiences in order to understand more fully the process of practice and effects on self and others in order to ensure quality control and demonstrate accountability.

West Pennine Health Authority (WPHA) began implementing clinical supervision as a project for practice nurses across Tameside and Oldham in 1998. Funds were secured from the Consortia following a pilot study that took place between 1996 and 1998 (see Figure 1).

[[NIP09_fig1_59]]

Development
Evaluation showed that this framework didn't foster engagement with the supervisory process or with the group. Some supervisors didn't feel equipped to facilitate groups following training. The size and frequency of the groups resulted in ad-hoc attendance, and the ­disparity in funding for time spent in clinical supervision acted as a barrier, which resulted in a lack of commitment from some supervisees. Overall, the pilot lacked direction and perceived value by some of those involved.

WPHA commissioned an evaluation of the pilot in 1998 from the Clinical Supervision Consultancy Service (CSCS), which included audit of the pilot framework and a survey of all participants. This resulted in recommendations for changes to the operationalisation of clinical supervision, which WPHA adopted as a basis for their implementation project. WPHA also participated in validation studies being carried out for the Manchester Clinical Supervision Scale (MCSS), which was being developed, the findings of which were incorporated into the new framework.(6) These include:

  • Longer sessions are better (60 minutes).
  • More frequent sessions are better (at least ­monthly).
  • Sessions in groups may be more effective (ratio 4:1).
  • Sessions away from the workplace may be better.
  • Supervisor trust/rapport higher if supervisor is chosen.
  • Impartiality of group composition may be more effective.

The culmination of the evaluation and the MCSS findings prompted major operational restructuring of the project to foster effective facilitation of supervisory practice and overcome the identified barriers to successful implementation (see Figure 2).

[[NIP09_fig2_60]]
 
Benefits
Following reorganisation and establishment of PCTs, Tameside and Glossop (TGPCT) and Oldham (OPCT) have continued to resource clinical supervision in keeping with advice provided by CSCS and evidence available from recognised research and evidence from the literature.(7) In addition, TGPCT and OPCT have continued to share resources, both human and financial, in relation to clinical supervision, which allows greater choice for those involved and a cost-effective use of funding available. Practice nursing and district nursing within Oldham are developing collaborations and resource sharing, as are practice nurses from Tameside and Glossop. Supervision for the supervisors continues to be provided by the CSCS, as does training for supervisors and preparation of supervisees, until such time as the expertise is developed within the PCT and self-sufficiency with regard to implementation can be achieved.

Annual audit conducted by the coordinators provides evidence of the ongoing effective facilitation of clinical supervision, and ensures networking opportunities for practice nurses often working alone and with increasing responsibility. Feedback received from the supervisors is encouraging - confidence is developing, which ensures that supervisees are enabled to engage with the process, thus allowing them to reflect on and critically analyse their practice and work experiences within intimate facilitated groups, where frequency fosters engagement and a safe environment for the experience to be both supportive and challenging, resulting in affirmation and learning. The PCTs benefit from this investment not only from its adherence to the directives, but also from practitioners who are further developing the skills necessary for safe, effective, responsible and accountable practice.

Conclusion
Both TGPCT and OPCT continue to invest in the ongoing implementation of clinical supervision for practice nurses. However, internally some aspects of the framework are being debated as a result of new management structures.

The cost of this implementation framework is modest - £14,000 for TGPCT and £20,000 for OPCT. Currently 46% of practice nurses in Tameside are involved in clinical supervision. A significant increase has been achieved over the past year as practice nurse attitudes towards clinical supervision have changed as a result of raising awareness and education and feedback to colleagues from those involved in clinical supervision.

Similarly, 33% of practice nurses in Oldham are involved in clinical supervision, and the increase ­experienced echoes that in Tameside.

If this framework continues, and if recruitment to the project continues, then all practice nurses within Tameside and Oldham will have access to regular, safe and effective clinical supervision.

References

  1. Wright H. Groupwork: perspectives and practice. Oxford: Sutton Press; 1989.
  2. Butterworth CA, Faugier J. Clinical supervision: a position paper. Manchester: School of Nursing Studies, Manchester University; 1994.
  3. UKCC. Position statement on clinical supervision for nursing and health ­visiting. London: UKCC; 1996.
  4. Department of Health. A vision for the future. The nursing, midwifery and health visiting contribution to health and healthcare. London: HMSO; 1993.
  5. Department of Health. A first class service - quality in the new NHS [HSC 113]. London: HMSO; 1998.
  6. Winstanley JB. Developing methods for evaluating clinical supervision. In: Cutcliffe J, Butterworth T, Proctor B, editors. Fundamental themes in clinical supervision. London and New York: Routledge; 2001. p. 210-24.
  7. Hadfield D. Implementing clinical supervision: a personal experience. In: Cutcliffe J, Butterworth T, Proctor B, editors. Fundamental themes in clinical supervision. London and New York: Routledge; 2001. p. 112-24.

Resources
W:www.clinical-supervision.com
The primary aim of this website is to help promote and support the development of clinical ­supervision in nursing

Further reading
Best D. Quality supervision: theory and ­practice for ­clinical ­supervisors. Philadelphia: WB Saunders; 1996.

Bond M, Holland S. Skills of clinical supervision for nurses. Buckingham: Open University Press; 1998.

Fish D, Twinn S. Quality clinical supervision in the health care professions - principled approaches to practice. London: Butterworth Heinemann; 1997.

Fowler J, editor. The handbook of clinical ­supervision:?
your questions answered. Wiltshire: Quay Books; 1998.