Nurses in primary care often work in isolation or within a small team that may have been static for a number of years.
The practice may not train students, meaning there is no throughput of new ideas and learning. Opportunities to attend educational events may be limited if there is no training budget and employers may not enable staff to attend sessions off site. It is then up to the individual to keep abreast of changes to guidelines and clinical best practice without a forum in which to share information or offer support.
Clinical supervision offers a protected space for a small group of nurses to meet and learn from each other, gain support and advice about their role and share the highs and lows of a career in general practice.
It is ‘a formal process of professional support and learning, which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations’.1 The Royal College of Nursing groups clinical supervision models into educative, supportive and managerial frameworks but suggests that models can be adapted to support the working environment as appropriate.2 All models focus on the concept of reflective practice, where participants are urged to make sense of events, situations and actions in the workplace.
The concept of clinical supervision for nurses is supported by the Nursing and Midwifery Council (NMC) in Enabling Professionalism in Nursing and Midwifery Practice.3 The NMC states that practice learning and development is enabled through ‘regular supervision and a focus on reflective practice’. The Care Quality Commission (CQC) views clinical supervision as good practice that helps to underpin regulations ‘17: Good governance’ and ‘19: Fit and proper persons employed’.4
The Lambeth model
Clinical supervision was first established in Lambeth in 2000. It is run by the authority’s clinical commissioning group and community education provider network (CCG/CEPN) nurse lead team using our original model. This model has been very successful and you can take elements to replicate elsewhere.
Training and organisation
Our first clinical supervisors were trained by a private provider, but recently we have used a two-day course run by South London and Maudsley NHS Trust for new group facilitators. Each group has between six and 10 members, most of whom are practice nurses, with a few from other community nursing backgrounds. We have also established three groups for healthcare assistants (HCAs). We meet every six to eight weeks and groups are held at a variety of times and across the week to suit the needs of the nursing workforce.
Lambeth CCG has 44 practices, more than 100 practice nurses and 35 HCAs. It is divided into three localities and the three nurses in the lead team each look after one. We visit all nurses and HCAs new in the post for a training needs assessment, and offer the option of joining a clinical supervision group.
There is a nursing section on the CCG intranet so nurses can browse the options for venues, timings, supervisors and allows them to approach the clinical supervisor directly to see if there is space to join the group. Nurses may not join a supervision group that a colleague already attends to ensure that individuals can discuss interprofessional issues freely.
Approximately 60% of Lambeth practice nurses and 70% of Lambeth HCAs are in supervision. Not all nurses and HCAs choose to participate; some have tried it and decided not to continue, others work in large organisations that provide similar services in-house. We are not aware of nurses being prevented from attending although clinical workload can sometimes be an obstacle. In a 2015 survey undertaken by the lead nurse team, 86% of respondents said that employers made it easy for them to attend clinical supervision.
The meetings follow a framework where the supervisor acts as facilitator: keeping time, ensuring active participation from all members, following up from the previous meeting and summing up at the end. Brief notes are kept by the facilitator along broad themes – eg clinical, professional, employment – and the members are encouraged to maintain a record both for professional development and to use as reflective practice accounts for revalidation.
There is a contract that details an agreement between supervisor and supervisee around timing, format of sessions, and members’ expectations of each other and of the facilitator. There is a specific confidentiality clause that outlines the requirement for the supervisor to disclose any breach of the NMC code of conduct should this come to their attention.5
Funding and making time
Clinical supervisors are paid £100 by the CCG for each session they provide. This takes into account the group supervision and any administration associated with running the group. We have nine nurse groups and three HCA groups – so assuming they each meet around six times a year, this is a total annual cost of less than £8,000. Supervisees attend as part of their working day, or claim the time back where this is not possible.
Updating the supervisors
The lead team organise an annual update for clinical supervisors to discuss their groups, styles of supervision, availability and issues arising within the groups.
We used an online survey in 2015 to audit clinical supervision in Lambeth for both HCAs and nurses. We received a 60% response rate. Of those, 80% said they regularly attended supervision, 85% felt that it improved their practice, 97% said it was good for sharing ideas and information and 95% felt it offered good support. We intend to repeat this survey in the first half of 2018.
As well as discussing clinical supervision at the first meeting with a new staff member, we regularly send reminders to those not in a supervision group and copy in practice managers. In our experience they can be good at encouraging staff to attend.
Retaining nurses and HCAs
Clinical supervision is valuable in reducing professional isolation, sharing best practice and offering support to staff who often work alone or in small teams. The lead team in Lambeth have found that supervision helps to retain staff by enabling nurses and HCAs to have insight into different working practices.
Supervision has had major benefits for our HCAs in enabling them to address misconceptions around accountability and delegation. They have also been able to share concerns about undertaking tasks for which they have not received training.
As we have comprehensively funded training in Lambeth, we have been able to provide certificated courses to address this and, as a consequence, we have a better trained and safer workforce providing care to our patients.
Nurses discuss practical elements of their role – such as accessing training and updates on immunisation, for example – but they also gain a great deal from discussing their workload and employers’ expectations. This can serve to reduce dissatisfaction when they compare themselves to colleagues and realise that what is being asked of them is reasonable. Equally they can feel empowered to address workload issues with their GPs and managers where perhaps they are not being given time to conduct aspects of their role.
With the absence of a national pay framework and widely differing terms and conditions in primary care, supervision is supportive in helping nurses and HCAs with negotiation skills and as a result, many have been successful in gaining better maternity pay and annual leave. The lead nurse team have published a recommended pay, terms and conditions framework to aid staff in initiating these conversations at the beginning and throughout their employment. Addressing this is key to recruitment and retention if we are to have a sustainable primary care workforce for the future.
Clinical supervision has far-reaching benefits for the nursing team in all aspects of their roles. Action 10 of NHS England’s ‘Ten Point Action Plan for General Practice Nursing’ cites establishing clinical supervision as a way to improve retention. CCGs now have a clear mandate to enable this to happen.6
- Department of Health. A Vision for the Future Report of the Chief Nursing Officer. London;NHS Management Executive:1993
- Royal College of Nursing. Clinical Supervision in the Workplace. London;RCN:2002
- Nursing and Midwifery Council. Enabling Professionalism in Nursing and Midwifery Practice. London;NMC:2017
- Nursing and Midwifery Council. The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. London;NMC:2015
- Care Quality Commission. Regulations for Service Providers and Managers. London;CQC:2017
- NHS England. General Practice – Developing Confidence, Capability and Capacity – a Ten Point Action Plan for General Practice Nursing. London;NHS England:2017