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Clinical supervision: supervision of supervisors

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: Rhona Jones
RGN SCM DipFC DipCHD DipDiabetes A51 Specialist Practitioner
Clinical Supervision Project Coordinator
Oldham West PCT

Margaret D Jones

RGN RM
A51 Specialist Practitioner
Clinical Supervision Project Coordinator
Tameside & Glossop PCT

A serendipitous finding of the evaluation project was that supervision of supervisors enhanced supervisor training and provided vital support for developing supervisors.(2) As a result a number of organisations such as Tameside and Glossop PCT and Oldham PCT have incorporated formal access to supervision for their supervisors within their ­implementation strategy.(3)
Although this additional level of supervision requires extra investment, the benefits gained justify the expense, especially within organisations where expert clinical supervisors are not available. The following are accounts by two supervisors of their experience of the supervision they provide to others.

Rhona's story
Before I became a clinical supervisor I hadn't taken part in clinical supervision. This was unfortunately the price of being one of the first wave of supervisors. I had read about the theory of clinical supervision and the benefits it could bring but I hadn't experienced them firsthand. The supervisors met regularly to discuss group dynamics, which in itself was extremely helpful. We were all new and sharing experiences helped us through the difficult periods. It also helped me to shape the future structure of groups avoiding previous pitfalls.
I felt strongly that supervisors needed their own supervision and I had the opportunity to ensure this when I became the coordinator of the Clinical Supervision Implementation Project for Oldham West PCT. Being a member of a group instead of facilitating one was a completely new experience for us all. Even though I knew far more about the theory and research of clinical supervision I still had the same fears and worries that I'm sure supervisees initially feel. Would I feel comfortable speaking in a group? Would I feel silly about raising certain issues? Would I go down in my colleagues' esteem if I mentioned something I do in my practice that they don't do? Even though I was strongly committed to clinical supervision these issues worried me and I was nervous and apprehensive at my first session. What if I actually realised that supervision wasn't as great as I had been led to believe and I was disappointed?
I am glad to say that I was not disappointed; if anything supervision has far exceeded my expectations. I have always felt comfortable raising issues and the support from the group members gave me confidence to talk about my practice, which resulted in changes and improvement. It is not, however, always comfortable; you are not sitting sipping tea and eating biscuits, having a chat. It is challenging, and when you are being asked to reflect on something you have always done, it can be uncomfortable to think that you may not have always been right. As the supervision group is confidential it allowed me to raise subjects that I feel I might otherwise have avoided. I also feel that it helped me with the supervision of my group. It opened my eyes to the normal fears and apprehensions that being in group supervision can bring.
Watching how an experienced supervisor handled certain issues helped. I had often felt that if I did not know the answer then it was my duty as a supervisor to find it. Of course that was wrong; we are all practitioners in our own right and as such we should find our own answers. The temptation to problem solve is always there and it is a skill in itself not to fall into that trap. To receive supervision from a more experienced supervisor allowed me to model skills that I was unsure about and develop the confidence I needed.

Margaret's story
I have been nursing since 1975, as a hospital nurse, a midwife and for the last nine years as a practice nurse. My memories of “clinical supervision” in a hospital environment are coloured by managerial and hierarchical structures. I remember standing in sluice areas discussing sometimes distressing events that had occurred on shift, with students who were only one or two groups ahead of me in training. I remember the odd lucky occasion in Sister's office, when an enlightened “senior” nurse took it upon herself to support and counsel “us learners”, thereby trying to ensure we had the necessary skills and knowledge to deal with the overwhelming tasks which were often asked of us. My memories of my supervisor of midwives are again quite varied. As a newly-qualified midwife I was in awe of my supervisor. Again, I was lucky in later years, although the role of supervisor was still managerial, the personality and caring attitude of the supervisor manifested itself insofar as I was treated with value and regard.
I had been practice nursing for four years before the idea of being involved with clinical supervision became an option. I attended an introductory session where we were encouraged and given the opportunity to reflect on practice, an essential element of maintaining professional development. The philosophy of clinical supervision was appealing, but also alarming. Practice nursing can be professionally isolating, due to shift patterns, part-time working, or the fact that learning only occurs within a small practice environment (often without peers) and perhaps “in house” updates are not as up-to-date as we think. Could I really be brave enough to share my professional thoughts and experiences with others, even in this nonjudgmental, safe, confidential environment? I experienced the whole gamut of emotions - fear, excitement, anxiety and doubt. Would I be laughed at? Would I be ridiculed? Would I be too embarrassed to speak? Well, not only did I proceed as a supervisee, I also progressed to become a supervisor.
So what are my personal reflections of being supervised as a supervisor in a group? Disturbing at first! Would I be criticised about my own facilitation skills? Would my own breadth of knowledge be shown to be inadequate? Had I listened intuitively to them? Conversely, as a supervisor would I be critical of my own supervisor? I knew the other group members quite well professionally and knew them to be strong willed. It was enlightening and somewhat alarming to experience the changing dynamics within the group. Our supervisor was very skillful and was able to keep the group focused. Over time, my fears abated.
One really positive aspect of being a supervisor in a group with other supervisors is having the freedom and the opportunity to bring issues that have been raised within my own supervision group. I may have feelings of uncertainty as to how I have left a supervisee, or doubts as to whether or not a suggested course of action had been thoroughly explored. It also allows me the opportunity to bring to it my personal uncertainties regarding my practice - the chance to review, analyse and evaluate an incident that was ­particularly distressing or challenging to me.
My supervisor is not a practice nurse, but this has not been a hindrance but an advantage. She gives clear constructive feedback on any issues discussed. She is an experienced nurse who brings her personality, her knowledge and her life skills to the group sessions. This has a knock-on effect for me. It gives me the confidence to confront my decisions, thus empowering me to move on, change or review my practice.
The initial group has changed over its three-year life-span but this certainly has not reduced the variety of topics being reflected upon. In fact it appears to be working better, by allowing time for indepth thought and discussion. Being a supervisor within a group has provided me with a formal professional support structure. It has allowed me to become increasingly aware of my own actions and reactions, thereby enabling me to continue to develop my professional practice and my skills as a supervisor.

Discussion
Clearly the supervision of supervisors group enabled Rhona to access an effective model of group supervision, which she was then able to recreate with her own group of supervisees as supervisor/facilitator in a supportive and continual learning environment
Both Rhona and Margaret are the clinical supervision project coordinators for their PCTs. The role of clinical supervision project coordinator allows dedicated time for the development, facilitation and evaluation of clinical supervision implementation. Volunteers can be sought, educational packages can be facilitated and information regarding the activity levels and quality of the supervision can be made available to the organisation to provide evidence to support continued funding. Bishop recommended that a clear, trustwide implementation strategy would yield quality evaluation.(4) While providing an identified lead for practitioners it also fulfils specific clinical governance requirements.
Rhona: "Now I look forward to my sessions and I would not miss one. It is also testament to our success that I am involved not only with leading the project for practice nurses, but also assisting the district nurses to secure clinical supervision and in addition the new healthcare assistants. It is going from strength to strength and I for one will welcome the day that it becomes compulsory for all nurses. Recently I spoke on clinical supervision at a clinical governance meeting. I was asked only one question. A GP wanted to know if GPs could have clinical supervision as he felt he was missing out!"
Margaret: "As the clinical supervision project coordinator I have an overview of all the clinical supervision activity among practice nurses within the trust. I am able to talk to practitioners individually, clarify their understanding of clinical supervision and help them make a start. I liaise with existing supervisees and encourage them to nominate themselves for supervisor training. By collaborating with Oldham and Stockport PCTs we are able to make the most cost-effective use of training resources."
Clinical supervision is a labour-intensive exercise. In reality practitioners do have difficulty finding time to fit it in so it is crucial that organisations and employers resource and facilitate clinical supervision for their practitioners through policies, protocols and cultural influence. After all, isn't clinical supervision good practice?

References

  1. 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.
  2. Butterworth CA, Carson J, White E, Jeacock J, Clements A, Bishop V. It is good to talk. An evaluation study in England and Scotland. Manchester: The School of Nursing, Midwifery & Health Visiting, University of Manchester; 1997.
  3. Hadfield D. Clinical ­supervision: ­experience within two PCTs. NiP 2003;9:58-9.
  4. Bishop V. Clinical ­supervision: what is going on? Results of a ­questionnaire. Nursing Times Research 1998;3:2.