Clinical supervision using the 4S model 1: considering the structure and setting it up
Despite recommendations, many nurses do not receive regular clinical supervision but with careful planning it is possible to create a successful comprehensive scheme
Carole Waskett, PGDip, BSc, Cert Supervision in Counselling and Therapeutic Relationships, Cert Solution-Focused Practice, trains and consults on teamworking, solution focused communication skills and supervision for NHS trusts, social services and charities
Waskett C (2010) Clinical supervision using the 4S model 1: considering the structure and setting it up. Nursing Times; 106: 15, early online publication.
While clinical supervision is recommended for all registered nurses, many still do not receive regular sessions. This three part series looks at how to integrate supervision into ’a trust’s everyday practice, using the 4S model.
This first part discusses the preparations trusts can make to give a scheme the best possible start. Part 2 examines the process of training new supervisors, while part 3 suggests ways to establish support for them and to sustain supervision.
Keywords Clinical supervision, 4S, Management
This article has been double-blind peer reviewed
Nurse leaders and managers planning to implement a supervision scheme should follow this advice:
- Don’t rush; think it through together first;
- Start with the basic systemic framework and policy;
- Do it in order: structure; skills; then support and sustainability;
- Plan for long term practice, not a short term “project”.
An older nurse commented recently: “In the old days, supervision for nurses used to be terrifying. Even not so long ago I remember going in with trepidation and coming out in tears - and that was a pretty common occurrence for many of us.” No wonder it has been so difficult to establish regular clinical supervision practice for health service staff in recent times.
The literature itself is of little help. While there are many useful pieces of work, almost all of it focuses on the practice or usefulness of supervision rather than its practical integration of clinical supervision into the organisation.
Not everyone goes without it, as several disciplines in the NHS must and do have regular supervision. Counsellors and psychotherapists, psychologists, art, music and drama therapists, play therapists, child protection workers and midwives (Nursing and Midwifery Council, 2008a) all have mandatory supervision. However, many disciplines, including nursing, have not yet incorporated it into everyday practice. Many nurses do not have regular, protected access to confidential conversations about the everyday challenges of their work, which would give them space and time to consider how they deal with increasing the quality of care with limited resources, and with ethical and moral issues such as delivering bad news or supporting distressed patients and families.
Research into the specific, evidence based benefits of clinical supervision is substantial, and its review is beyond the scope of this article. In general, these benefits include staff who are more rounded and responsible, who use, develop and reflect on every element of their capacity and therefore work more confidently and effectively. And where staff feel cared for by management, committed to their work, and are constantly learning and supporting each other (Senge et al, 1994), this has implications for improving morale and staff retention and reducing burnout and sickness levels (Hyrkas et al, 2006). The standard Department of Health documents establishing national policy continue to advocate the use of good staff support as part of clinical governance, as do all professional bodies including the NMC.
The NMC (2008b) strongly and specifically advocated regular clinical supervision for all registrants. Butterworth and Woods (1998) stated: “Participating in clinical supervision in an active way is a clear demonstration of an individual exercising their responsibility under clinical governance. Organizations have a responsibility to ensure that individual clinicians have access to appropriate supervision and support in the exercise of their joint and individual responsibilities.”
The DH (2006) specified good governance and staff support throughout, for example: “Health care organisations [should] ensure that staff concerned with all aspects of the provision of health care…participate in further professional and occupational development commensurate with their work throughout their working lives.”
Neglecting or abandoning the idea of clinical supervision is, therefore, not an option. However, it is not a job for individual clinicians. If a system of supervision is to be successful, the whole trust must take on the task.
Making it happen: the 4S scheme
If a trust has made a clear decision to integrate clinical supervision into its clinical governance, it is possible to create a robust scheme in which all those who work with patients access supervision, either one to one or in small groups. This can and should be collaborative and encouraging, even enjoyable; something that staff are eager to attend and find helpful in their work. The 4S scheme (Waskett, 2009a; 2009b) uses four essential ‘S’ elements to establish a robust and useful scheme: structure, skills, support and sustainability. This is a systemic approach in which each element locks into the others and contributes an essential part of the overall scheme. This article addresses structure, while the other three elements are discussed in subsequent articles.
Large complex bureaucratic organisations like NHS trusts can be difficult places in which to introduce new initiatives. These organisations are in a state of endless change, and introducing yet another can be daunting; everyone always feels under pressure. One of the dangers of this situation is that employees may feel isolated and alienated. Good supportive supervision is one way to remedy this.
Often, clinical supervision is “fudged” and slipped in under the headings of management supervision, appraisals, one to one meetings with team leaders, or even team meetings. While these are essential elements of working life, they are not clinical supervision. This distinction is so important that at least one large organisation with its own excellent supervision scheme calls it “non management supervision” (Hill, 2005) to make it absolutely clear.
In the past, many trusts had written policies on supervision and some staff may have been trained as clinical supervisors. However, anecdotal evidence indicates that these staff members may or may not be able to maintain supervision practice; their training can be costly and may seldom be used. Hawkins and Shohet (2003) described exactly this experience as trainers. In these instances, while supervisors may have been trained, their employing organisation has not been helped to do the necessary structural work which enables them to use their new skills effectively. However, if organisations can start from scratch, it is wise to begin with considering the structure and processes necessary to enable a supervision scheme to flourish. Box 1 outlines useful questions for nurse managers.
Box 1. Questions to consider
- Does your trust have a clinical supervision policy?
- Is it supported from the top?
- Has this translated into regular practice for all who are eligible?
- Do you have enough trained supervisors to meet the need?
- Do you have active monitoring and evaluation?
Starting from scratch
Among those identified to lead and guide the establishment of the supervision scheme should be someone senior and high profile whose backing will be visible and influential across the organisation. Senge et al (1994) recommended starting at the top when making this kind of systemic change. Without this, the scheme is likely to fail.
A small group of managers with the authority to make things happen can now take on the role of planning and preparing for the scheme, writing or reviewing policy and other necessary paperwork, and agreeing processes. It is important to do this before supervisors begin training, as the training can then be tailored to take account of the local policy and protocols developed. The following decisions affect how the training is tailored to the organisation (Table 1) (part 2 of this series outlines the later stages involving training, starting the scheme and evaluation). The sections below outline some of the choices, decisions and actions the lead group makes at this stage.
Small group or individual supervision?
One to one work is flexible and closely tailored to individuals, and enables supervisees to explore personal issues because of the confidentiality of the relationship. In groups, much time is saved as up to eight people share a two hour supervision slot. Not everyone has to present every time (which may or may not be an advantage) and people learn from and support each other. But there may be confidentiality issues, and thought should be given to how much group members interact outside the supervision group. The group setting may inhibit certain relevant issues being aired. Finally, practitioners, or the trust, may have strong personal preferences for one or other type of supervision.
How many supervisors need to be trained and available?
We can make some basic assumptions that:
- Supervision sessions (group or individual) occur every eight weeks;
- Groups comprise up to eight people;
- When fully trained and up to speed, each supervisor can be given protected time to supervise three groups or five individuals every eight weeks;
- One hour of one to one or two hours of group supervision requires around 1.5 hours or 2.5 hours respectively of supervisor time for preparation/paperwork/travel. If individual supervision is the model of choice, typically 17% of the eligible workforce needs to be trained. If group supervision is specified, then only about 4% needs to be trained. This is a powerful economic argument for group work.
Should supervision be mandatory or optional?
And for whom would it be mandatory? All staff? All clinicians? It is only possible to make non managerial supervision mandatory if there are enough trained supervisors to offer the service to all staff. A great deal of awareness raising would need to be carried out, and a decision made as to who would police and enforce the ruling.
One variation, recently put into operation by Salford Community Health, the provider arm of Salford NHS, involves making joint training courses for both potential supervisors and supervisees compulsory for all clinical staff. As participants finished their courses they were expected to begin to carry out regular supervision, so there. was a growing body of staff using supervision while new trainees were joining courses behind them. Monitoring takes a high priority in this method.
Salford’s scheme is non hierarchical and multidisciplinary – an excellent model. The key to doing this type of supervision well is having the collaborative language skills to help supervisees (or groups) develop and expand the quality of their work, as well as having a firm grasp of the ethical and boundary issues involved. In this approach, supervision is not about offering solutions or giving advice, but about eliciting the strengths, decision making and expertise of supervisees.
If optional, how should the scheme be marketed?
If possible, marketing expertise should be used to target the scheme at potential supervisees. One or more of the lead group could be invited to team meetings to explain the new type of supervision. There needs to be an appreciation of any current supervision used, provided it works and is useful - in the opinion of both supervisees and supervisors. Newsletters and bulletins can carry short and encouraging messages, and of course the senior, influential person’s name should be used. Middle managers need to be engaged, so they can make it possible for their staff to attend sessions.
How many supervisees?
The number of individual supervisees and/or groups each supervisor is expected to haveshould be specified in the policy so that supervisors do not feel obliged to take on more than they can manage. Supervisors should always be in control of their supervision workload (with their managers’ permission) and should be able to refuse requests if necessary. Though policy may specify, perhaps, up to five individual supervisees or three groups (or a mix) in any one eight week period, newly trained supervisors may not feel confident to take more than one (individual or group) at the start, increasing this as they gain experience.
Frequency of supervision sessions
This depends on the organisation’s resources. It is wise to book dates well ahead for all concerned. Managers should always know when their team members will be at supervision and for how long, so they can plan service provision. Supervision sessions should never be interrupted except in an emergency.
Protected time for supervisees
Supervisees need one hour per session if they are working one to one with their supervisor, certainly for at least the first year. With time and practice, a partnership may be able to reduce this without compromising the effectiveness of supervision. Sharry (2007) and Norman (2003) suggested how groups of up to eight can be effective in a two hour slot by using certain techniques and structures.
Protected time for supervisors
Table 2 shows that for a supervisor to supervise one group and one individual, the trust’s time outlay over a year is around 38.5 hours. However, this does not take account of sickness/annual leave and other delays, and assumes a 52 week year. Also, as supervisors gain experience they will be able to take on more individuals/groups without needing additional supervision and support themselves. They may also be able to reduce one to one timing as they and their supervisees gain experience. Groups can in time be taught how to self supervise using specific techniques, perhaps with “arms length” support from a supervisor.
Nevertheless, supervision is not a task to be minimised, skimped or fitted round other duties. It should be taken seriously and written into job descriptions. It is a skilled and demanding role in itself. Depending on much value allocated to supporting staff, some trusts may choose to write job descriptions in which substantial hours are allocated to supervision duties.
Supervisors should not have a management role or power gradient in relation to those they supervise, to avoid any accountability/management issues. The lead group needs to consider how to support and supervise supervisors in the early stages of setting up the scheme, which is discussed in part 3 of this series.
How should the scheme be monitored and evaluated?
Supportive supervision is a costly investment in staff and must, therefore, be monitored and evaluated. The lead group will consider this as part of the scheme’s framework. As this is a confidential activity, no material discussed can be made public, but the question of who takes part in supervision, and when, are legitimate questions. A sign in sheet for each session (whether individual or group) can be collected, so that at the end of a certain time it is clear how many staff use supervision and how often. Evaluation is also necessary and the main issue at this point for the lead group is to decide whether they wish to record some baseline data for comparison later (also discussed in part 3).
Write policy, contract, monitoring sheets and any other documentation
Having made the previous decisions, writing this documentation is fairly simple. Ratifying the policy could be delayed until the scheme is up and running, which would enable any practical amendments to be made later.
Given this thorough grounding and preparation, the supervision scheme will have a good start and within a year or so will no longer be a “scheme” but a widely used, natural and invaluable part of professional practice.
- Part 2, to be published in next week’s issue, discusses in house training for supervisors
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Department of Health (2006) Standards for Better Health. London: DH.
Hawkins P, Shohet R (2003) Supervision in the Helping Professions. Maidenhead: Open University Press.
Hill J (2005) Professional supervision boosts feelings of personal accomplishment AHP Bulletin; 35: 6.
Hyrkas K et al (2006) Efficacy of clinical supervision: influence on job satisfaction, burnout and quality of care. Journal of Advanced Nursing; 55: 4, 521-535.
Nursing and Midwifery Council (2008a) Modern Supervision: A Practical Guide for Midwives. London: NMC.
Nursing and Midwifery Council (2008b) Clinical Supervision for Registered Nurses. London: NMC.
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