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Clinical supervision: a supervisor reflects

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

Contributor: Christine Amsden
MSc RGN
Nurse Practitioner
Albion Medical Centre
Tameside and Glossop PCT

Clinical supervision is an activity that is peer-led(1) and "for practitioners by practitioners",(2) and it is common that supervisees and supervisors are of a similar grade and seniority. This differentiates it from management supervision. However, for effective clinical supervision to take place, clearly defined roles and responsibilities are required. Formal education and training for clinical supervisees and supervisors is essential.(3)
The previous article in this series described the anxieties experienced by a supervisee as she embarked on clinical supervision (NiP 2003;10:60-1). The reflections here are by a nurse practitioner clinical supervisor.

Chris's story
I have worked in general practice for 13 years, initially as a practice nurse and, after completing an MSc in clinical nursing, as a nurse practitioner, gaining wide experience in these roles. In addition to traditional practice nurse activity, my role also includes taking histories and conducting examinations in order to diagnose. I triage and screen all visits, assessing urgency, suitability and need for referral to another member of the primary healthcare team (PHCT). Collaboration is necessary for patient management and healthcare delivery and for managing the ­anticoagulation clinic.
I am a member of the Education and Training sub-group of the primary care trust (PCT) and am involved in the introduction, planning and implementation of new policies, programmes of care and initiatives within the PHCT. I am also involved in the organisation of training strategies for PHCT members across the PCT, in particular relating to anticoagulation ­services and teenage sexual health.
It is well known that practice nurses and nurse practitioners in general practice often work in isolation due to the nature of their work, and clinical supervision provides the professional and clinical support needed. I am involved in clinical supervision as a clinical supervisor as well as a supervisee and am aware of the fears and anxieties nurses may have when embarking on this initiative. There are many misconceptions and confusion about clinical ­supervision, and comparisons are made with trust and management initiatives like appraisal, performance review, disciplinary procedures and even “spying” - observation of professionals by other professionals. I now realise that this is not true.
I, like so many other nurses, had many anxieties and fears about clinical supervision and attended an introductory training day to find out more. I had concerns around confidentiality, the different personalities in the group, conflicts of interest and whether I would be able to talk freely. I wanted to know what I would get out of it - would I get time out of work or would this be yet another thing to do in my “own time”? My main concern was management and whether I was being “policed”.
Attending the training day allayed any fears I had, and I was reassured that everyone felt the same.
I then joined a supervision group as a supervisee and continue to be a member, finding it invaluable.
After some time as a supervisee I was approached and asked whether I wanted to become a supervisor and attend the three-day training course. The course confirmed to me that good organisational and interpersonal skills, as well as the need to be self-aware and able to reflect on one's own practice, are essential requirements for being a supervisor. My fears centred on whether I had the knowledge and skills to lead a group. As a supervisee I had the experience of the supervisor of my group, how she managed the group and used different models and other members of the group to achieve a positive outcome.
Many issues can be highlighted during clinical supervision, and a good working knowledge is needed of referral policies, clinical practice, professional and legal issues, and where to access information. I realise I do not know all the answers, but the group I belong to acts as a good model and allows access to a network.
My first experience as a clinical supervisor was a one-to-one session, which gave me valuable experience and confidence in preparation for when I was asked to run a group. I had anxieties about who would be in the group, whether they would “know” more than me, and whether I would be able to do them justice and make it a positive experience. The first session was taken up with “getting to know” each other, discussing ground rules, writing and signing a contract, particularly clarifying the confidentiality issue. Many issues are discussed in an open and nonthreatening manner in confidence - practice policy, work conditions, legal, clinical and professional issues.
An example of an issue brought to a session involved a practice nurse who had been approached by her practice manager to perform blood tests at a reduced pay scale (permission has been given by the nurse to discuss this issue). It was felt by the group that the majority of practice nurses do not “just” take blood, that invariably patients will ask for advice about illness or treatment, or request a blood pressure check or an injection if due. The group decided that perhaps the best solution to this problem was to do a “mini-audit'” for the forthcoming month on the number of patients attending for a blood test who requested further advice and treatment. A meeting was then arranged with the practice manager to discuss the findings. The practice manager was not fully aware of the reality of the situation and agreed it was not appropriate to expect the practice nurse to perform blood tests at the reduced pay scale.
On reflection, having had experience of supervising both one-to-one and group sessions, I feel the group works better. In the one-to-one sessions discussions were generally about protocols, guidelines and pay scales, and I found myself providing guidance and solutions instead of allowing the supervisee to work things out for herself. In the group the other members discuss the issue as it relates to themselves and their own practice, reflecting on what they may do in the same situation to resolve the problem. I am there to facilitate the group and keep the discussion flowing to a successful conclusion.
My involvement in clinical supervision has made me more self-aware and helped me in my own professional and clinical role. My confidence in dealing with professional issues and accessing information has increased, and I have become more assertive, particularly in dealing with problems that arise in my own field of work.
The experience I have had as a clinical supervisor has reinforced my belief that the majority of practice nurses work in total isolation without the management support our colleagues in secondary and community care are privy to. Those practice nurses that I talk to who are involved in clinical supervision all confirm and stress the importance and value of clinical supervision not only for themselves, but also particularly in relation to their professional and clinical practice.

Conclusion

Both supervisors and supervisees have the same anxieties about clinical supervision. Formal training for the supervisor role helps supervisors develop the skills to provide effective, accountable and confident supervisory practice.(3) Not only does clinical supervision have a positive impact on the practitioner's performance esteem, as described by Chris, but it also allows reflection on and greater understanding of responsibility and accountability as mandated by the Nursing and Midwifery Council's Code of Professional Conduct.(4)
The benefits for the organisation are also clear - safe practice is ensured through this process of reflection and critical analysis, which allows a review of practice procedures while protecting all concerned - the practitioner, the patient and the organisation.
The final article in this series will consider the needs of supervisors and how supervision of the supervision they offer others provides for this. In addition, insights are gained into the role of the clinical supervision project coordinator within the two trusts.

References

  1. Butterworth CA, Faugier J. Clinical supervision: a position paper. Manchester: School of Nursing Studies, Manchester University; 1994.
  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: School of Nursing, Midwifery & Health Visiting, University of Manchester; 1997.
  3. Coleman M, Rafferty M. Using workshops to implement supervision. Nursing Standard 1995;9(50).
  4. NMC. Code of professional conduct. London: NMC; 2002.

Further reading
Cutcliffe JR, Epling M, Cassedy P, McGregor J, Plant N, Butterworth T. Ethical dilemmas in clinical supervision: 1 and 2. Need for guidelines. Br J Nurs 1998;7

Proctor B. Training for the supervision alliance attitude, skills and intention. In: Cutcliffe J, Butterworth T, Proctor B, editors. Fundamental themes in clinical supervision. London and New York: Routledge; 2001. p. 25-46

Rafferty M, Coleman M. Developmental transitions towards effective educational preparation for clinical supervision. In: Cutcliffe J, Butterworth T, Proctor B, editors. Fundamental themes in clinical supervision. London and New York: Routledge; 2001. p. 84-95