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Clinical supervision: a working perspective

Annette Mitchell
RN DN DipHSW(Open) BSc(Hons)
District Nurse
Derwent Surgery
Malton
North Yorkshire
E:Annettemitchell@btinternet.com

There are many different models and definitions of clinical supervision, but for us the most useful and relevant one is:
"Clinical supervision is regular protected time for facilitated in-depth reflection on clinical practice. It aims to enable the supervisee to achieve, sustain and creatively develop a high quality of practice through the means of focused support and development."(1)
Throughout the last decade of dramatic and continuous healthcare changes, clinical supervision has been a cornerstone in both government and nursing (eg, the UKCC and ENB) policies of active support for frontline nurses.(2) It is seen as a mechanism to underpin clinical governance programmes,(3) thus enabling community nurses to cope with all the new initiatives (eg, nurse prescribing and earlier hospital discharge). These initiatives have added an extra dimension to the autonomy, clinical responsibility and diversity of practice of a group of nurses who are traditionally seen as autonomous, resourceful but mainly solitary decision-makers.(4) The positive effect of group support to reduce workplace stress and improve patient care has been proven for nearly 20 years,(5) and the effect and effectiveness of clinical supervision itself is well documented(6) (it has long been an integral part of practice for psychiatric nurses). Clinical supervision is perceived as good, desired practice, but no one has made it mandatory, which might explain its piecemeal implementation. In fact despite all the glowing recommendations, fewer than 47% of district nurses receive any annual clinical supervision.(4)
So how did we begin when many other areas are still struggling to set up groups? As with many trusts, clinical supervision was encouraged and courses were attended, but it had no formalised structure. Its implementation was through the effort of one committed champion, who put it on the agenda of our monthly district nurse meeting. Encouraged by the support of our locality manager, who allowed time out during the working day for clinical supervision (and an enthusiastic response by all who were present), an open meeting was called to discuss how to move forward. There are many recommended models of clinical supervision - one-on-one, self-supervision, peer group(3) - but taking the guidance of research, we decided on a group model.(7) Our groups are made up of about five registered nurses from a mixture of district nursing and health visiting disciplines. Most groups are mixed except one group, which preferred to be a single-discipline group.
There were many reasons why we plumped for this model. It was feared that self-reflection can lead to insecurity and self-doubt, but it was anticipated that groups from different areas of the locality would ensure adequate attendance levels and attempt to guard against split loyalties (so junior colleagues were not placed in the same group as their line managers). Groups were carefully formulated to try to promote ease of disclosure and discussion.
Next we had to decide the fundamental principles - that is, the ground rules. As experienced practitioners we realised that the success of the initiative depended on clear parameters - professionally, legally, ethically and personally. It was agreed that all members of the groups had to sign up to all of them.
Confidentiality was uppermost in our agenda, but there were reservations. Anything conflicting with our code of conduct was to be reported, as failure to do so could result in disciplinary proceedings by the NMC8 and legal liability.(9) Patients' identities must remain confidential. Commitment with regular attendance and courtesy and tolerance were other, obvious ground rules.
The location/environment was the next consideration, as this had to be somewhere conducive to counselling. We usually meet after lunch in a warm, secure and private room. There is coffee available, and chairs are arranged to make the most of our sometimes formal meeting rooms. Pagers are usually switched on but we do try to keep disruptions to a minimum. A central location is chosen, because, as with the rural nature of our practices, we are spread over a wide geographical area.
We have protected time but we limit the session to one hour. To make the most of our time, we decided to use a guide/model to work by. We chose a "client- centred model of supervision", as proposed in the clinical supervision course (2000) from the University of York.(10) This aims to help people identify and clarify their own issues, then make a commitment and a plan to deal with them. We feel that nurses are more at ease with this model because it has an emphasis on action and change, which are integral parts of the nursing process.
We start by throwing open the floor, so that anyone who wishes to can discuss any nursing issues. Facilitation is a shared responsibility of the group. One member of the group is an experienced practitioner in clinical supervision and often leads facilitation; however, when this person brings issues to discuss, others have to take more responsibility for facilitation, changing the group dynamics.
Nurses often worry about using "models" correctly. To help simplify and demystify the process I found the work of Rogers (a pioneer of group counselling) extremely helpful.(11) Rogers says that group reflection should be likened to holding up a mirror to that person, so that they can truly see themselves. Thus all questions should be aimed at ensuring the reflection will be a true image. He also valued spontaneity, believing that a naive member often has an inner wisdom for dealing with different situations.
Although setting ground rules and using a model is very useful, it does not solve all problems. Commitment was a fundamental ground rule, but that old nursing ethos - "workload always comes first" - sometimes gets in the way. Despite clinical supervision being regarded as a mandatory need/right, not a luxury, the reality is that sometimes it is a real physical problem to get through the necessary daily workload, and attendance has fallen in some groups. Clinical supervision is always more successful in NHS trusts where it has protected time.(4) As a team we have recently made a commitment to support each other to ensure that we can attend. However, not every community nurse has signed up to clinical supervision. Some find the process very alien and fear it is a fault-finding tool of management, and/or still see admitting problems as a weakness.(1)
At present clinical supervision is not mandatory, allowing practitioners to opt out of the process and withhold support for practitioners trying to attend. But if attendance was mandatory, such reduced commitment might make for poor integration into the groups.
Many of the members of our groups have not had any formal training in clinical supervision, and this remains a concern, particularly regarding the role of supervisor. Courses have been run by our trust about clinical supervision, but not everyone has attended. Limiting clinical supervision to only those who have received training seemed unfair. As counselling (in a variety of forms) is a fundamental part of our daily nursing practice we decided to wait no longer. Experienced practitioners in clinical supervision were spread throughout the groups and we were each given a small introduction pack, which contained a reading list, the model we had chosen and some brief notes on clinical supervision. As we progress it is hoped more will access available training. Besides the local course run by the University of York, there are a variety of other courses (see box below).
Another potential problem that we have fortunately not encountered is that the supervisor can be held responsible for negligent or inappropriate advice, especially if this was to result in harm befalling the supervisee or a patient.(9)
Evaluation is a vital part of the nursing process, so one year on where are we? The good news is that all the groups are still meeting. Audit will probably be the next step, especially in a culture that needs hard paper evidence to justify resources. The government suggests that it takes two years before you can realistically audit the effect of any new staff counselling service,(12) and this would appear a sensible timespan. The University of Manchester has developed a tool for measuring the impact of clinical supervision, which has been validated by the government and appears quick and easy to use.(3)
What else have we found? Well-mixed peer groups from different areas of the locality seem to promote greater understanding and integration. Also, practitioners from different disciplines have sometimes offered  innovative, occasionally money-saving solutions. A member has also raised the point that, although patients cannot bar their nurses from clinical supervision, good practice would indicate that they should be aware of it,(9) so notification could be integrated in a proposed new mission statement.
The government states that for clinical supervision to be a continued success there must be an understanding between all involved parties (management and staff) of what the purpose of clinical supervision is and how they will fulfil that purpose.(3) Within our trust support is growing, with the PCT recently referring clinical supervision to our shared governance forum, with a view to trustwide implementation. Staff involvement in the process of development is key to success,(3) but here, thanks to the initiative and drive from a few individuals, clinical supervision has had a grassroots introduction.

References

  1. Bond M, Holland S. Skills of clinical supervision for nurses. Buckingham: Oxford University Press; 1998.
  2. PCT lead nurses - leading the ­delivery. Speech made by John Hutton, Minister for Health, at Victoria Park Plaza Hotel, London; 8 July 2002. Available from URL: http://www.doh.gov.uk
  3. Department of Health. Making a difference: clinical supervision in primary care. London: Department of Health; 2000.
  4. Audit Commission. First assessment. London: Belmont Press; 1999.
  5. Motowidlo SJ, Packard JS, Manning MR. Occupational stress: its causes and consequences for job performance. J Appl Psychol 1986;71:618-29. Cited in: Messer D, Meldrum C. Psychology for nurses and health care professionals. Hemel Hempstead: Prentice Hall; 1995.
  6. Butterworth C, Faugier J. Supervision in nursing midwifery and health visiting: a briefing paper. Manchester: School of Nursing Studies, University of Manchester; 1994.
  7. Griffiths J. Group clinical ­supervision in district nursing. Br J Community Nurs 1999;4:2.
  8. Nursing and Midwifery Council. Code of professional conduct. London: NMC; 2002.
  9. Dimond B. Legal aspects of clinical supervision 2: professional ­accountability. Br J Nurs 1998;7:487-9.
  10. The University Of York. Clinical supervision course 2000 - "A client centred model of supervision". Taken from: Dexter G, Walsh M.Psychiatric nursing skill. London: Chapman and Hall; 1995; and Russell J. Out of bounds. London: Sage; 1993.
  11. Kirschenbaum HL, Henderson V. The Carl Roger reader. London: Constable; 1997.
  12. Department of Health. The ­provision of counselling services for staff in the NHS. London: Department of Health; 2002.

Resources
Clinical Supervision
website
W:www.clinical-supervision.com

Department of Health
W:www.doh.gov.uk

NMAP
Guide to internet resources in ­nursing, midwifery and the allied health professions
W:nmap.ac.uk

Graduate Research in Nursing
W:www.graduateresearch.com

National Board for Nursing, Midwifery and Health Visiting for Scotland
W:www.nbs.org.uk

The Bevan Library
W:www.beds-med.demon.co.uk

University of Nottingham
W:www.nottingham.ac.uk

Health and Social Services Website for Northern Ireland
W:www.n-i.nhs.uk

Department of Nursing and Midwifery
University of Sterling
W:www.nm.stir.ac.uk

Further reading
Butterworth T, Faugier J. Clinical supervision and mentorship in nursing. London: Chapman and Hall; 1992.

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

Royal College of Nursing. Clinical supervision of practitioners. London: RCN; 1994.

UKCC. Position statement on ­clinical ­supervision for nursing and health visiting. London: UKCC; 1995.

The University of Manchester. Manchester ­clinical ­supervision scale. For sale with instruction manual from Helena Hall
T:0161 2755336
E:helena.hall@man.ac.uk