VOL: 98, ISSUE: 23, PAGE NO: 30
Robert McSherry, MSc, BSc, DipN, RGN, is principal lecturer, practice development, School of Health and Social Care, University of Teesside;Jenny Kell, MA, RN, is senior lecturer, practice development, School of Health and Social Care, University of Teesside;Paddy Pearce, MSc, BSc, RGN, is clinical governance manager, Friarage Hospital, Northallerton
What is clinical supervision and how does it relate to clinical governance in nursing practice?
Faugier and Butterworth (1994) define it as a process that promotes personal and professional development within a supportive relationship that is formed between equals. Clinical supervision aims to promote high clinical standards and develop professional expertise by supporting staff, helping to prevent problems in busy, stressful practice settings.
Robust systems and processes are needed if effective clinical supervision is to be carried out. Discreet line-management structures that address actual and potential problems should ensure that high standards of practice are maintained.
In nursing practice, the objective is not to have a managerial supervisory process but to use clinical supervision to develop personal and professional standards. McSherry and Pearce (2002) suggest that it is about developing a framework within which staff can identify and explore issues surrounding the quality of the care delivered. This framework should also enable staff to identify their education and training needs, allowing them to improve their clinical competence.
Clinical supervision should not be seen as a way to blame staff if things go wrong. It is about promoting an ethos of openness and honesty in the practice setting, using reflection to develop and enhance practice. It can be used as a tool to promote a person’s awareness of the strengths and weaknesses in their practice. It should be used to review practice and make changes when problems are encountered.
Implementing a framework for clinical supervision
Several conceptual models outline the theoretical basis of clinical supervision but are limited in their practical application (Proctor, 1986; Faugier and Butterworth, 1994). Bassett (1999) provides a comprehensive, simple, practical guide to researching, implementing and evaluating clinical supervision in practice. The following section builds on the work of Bassett (1999) by not only identifying the different approaches - group, one-to-one and peer - that can be used to provide clinical supervision but also outlining the advantages and disadvantages of each.
A group of practitioners meet to discuss an event from practice. The discussion may involve:
- An individual presenting a predetermined topic;
- An individual presenting a personal development topic;
- The group discussing issues raised from an audit of practice;
- The group discussing a clinical case and how care can be improved.
All these options are based on the premise that discussion of the topic will ultimately lead to improvements in practice. Group supervision in this context enables the work to be shared among the participants but there are some advantages and disadvantages to this system (Box 1).
One-to-one supervision offers people a way to discuss and develop their personal and professional practice. Working with someone who is more experienced in a particular setting helps staff to develop their knowledge and skills. Much like group supervision, one-to-one supervision has its advantages and disadvantages (Box 2).
Peer supervision should be carried out with a group of staff who are at the same level of practice. This should enable people to share and learn from past and current experiences in a non-threatening environment. The advantages and limitations of peer supervision (Box 3) relate to the removal of imposed supervision of practice and the issue of how people learn from someone of the same grade.
One of the problems in implementing clinical supervision, regardless of which approach is used, is finding the time to do it. Streamlining shift patterns to avoid having too many staff on duty at any one time has, in effect, limited the time available to hold clinical supervision sessions. Clinical supervision should be an integral part of practice and, as such, should be part of the working week. Staff should not be expected to do it outside their working hours.
Within clinical governance, clinical supervision is an essential component in safeguarding and ensuring quality practice. Clinical supervision should be seen as a leading factor in encouraging and supporting the development or evaluation of practice, be it at an individual, team or organisational level.
So how does clinical supervision relate to clinical governance?
The clinical governance frameworks
Clinical supervision and clinical governance are not interchangeable. They are two separate, but essential, concepts that encompass the principles of continuous quality improvement. Clinical governance is viewed by the NHS Executive (1999) as a systematic set of mechanisms that will support staff and encourage organisations to develop new approaches to improving quality. In Making a Difference (Department of Health, 1999), the government clearly set the agenda for nursing by ensuring that the profession was in the vanguard of clinical developments. In particular, this includes:
- A role for nurses, as the catalyst in the implementation of national service frameworks;
- A focus on quality;
- Implementation of evidence-based practice;
- Input to the research-and-development agenda;
- Taking the lead in monitoring the delivery of the quality of care.
In the context of clinical governance, it is clear that everyone is responsible for ensuring quality. But this can be achieved only if enough support is provided to staff in the practice setting. In real terms, this should mean allocating a specific time to do this and putting in place a structured framework to enable the process to take place. Within clinical governance, clinical supervision is a key ingredient in improving quality through staff support and development.
So how can clinical governance and clinical supervision work together in practice? All trusts and practice areas should have identified clinical governance leads who will, in many cases, be members of the executive board. It is their responsibility to implement clinical governance initiatives across practice areas. Clinical governance is about:
- Addressing quality issues in practice, such as dealing with clinical incidents/risks and complaints;
- Setting practice standards;
- Benchmarking standards of practice and auditing the levels of practice achieved;
- Improving practice and care for patients and clients who use the service;
- Supporting staff and promoting lifelong learning.
It is evident from the criteria for clinical governance set out above that clinical supervision is an integral part of quality improvement and lifelong learning. For clinical governance to be successful staff need to be supported and helped in maintaining, monitoring and developing their practice at individual, team and organisational levels.
Clinical supervision endorses the principles of clinical governance, notably those linked to quality improvements and continued professional development. These principles are put into practice through the application of a model of clinical governance to show how clinical supervision supports the quality improvement agenda and lifelong learning. For example, Proctor’s (1986) model identifies three elements associated with achieving effective clinical supervision: formative, restorative and normative.
The formative element refers to learning about practices by reflecting on personal experience, with a view to evaluating the practice with others. The restorative element is linked to the supporting processes required to review, evaluate and, if necessary, change practice. The normative is about encouraging staff to review and change practice, according to the best available evidence, in the pursuit of excellence.
A critical review of Proctor’s model clearly shows how clinical supervision can be applied to implement certain aspects of the clinical governance framework. It can be applied in the following areas:
- Quality improvement;
- Staff support;
- Continued professional development and lifelong learning;
- Evidence-based practice.
The outstanding issue for health and social care staff is how to link clinical governance with clinical supervision.
Linking the clinical governance framework with clinical supervision
Fig 1 (overleaf) illustrates the similarities between clinical governance and clinical supervision, as both processes are about advancing and enhancing practice at either individual, team or organisational level. Box 4 (overleaf) shows the relationship between the five stages associated with implementing both clinical governance and supervision.
In practice, clinical governance is about how the organisation supports collaborative working by involving users - to enhance performance in the quest for improvements in quality. It is also about demonstrating the efficiency and effectiveness of individual, team or organisational practices.
Similarly, clinical supervision should be a part of the clinical governance framework in all practice areas: it should offer staff the opportunity to share and discuss issues in practice in their quest for better quality. Carried out correctly, clinical governance should embrace the concept of clinical supervision.
To engage in clinical supervision, as part of the clinical governance framework, teams and organisations need to invest in the framework (Fig 1), which shows how the five stages associated with implementing clinical governance and supervision are related. This is not an easy task. Organisations will need to:
- Encourage a culture of openness and honesty;
- Encourage multidisciplinary working;
- Ensure that staffing levels create an opportunity to manage change effectively;
- Provide support mechanisms that are useful and used by staff;
- Encourage staff involvement in decision-making;
- Provide staff appraisal systems that work;
- Develop open lines of communication and access to information.
The challenge for implementing clinical supervision within the clinical governance framework is in breaking down the barriers in the organisation.
Barriers to effective implementation
McSherry and Pearce (2002) identify the barriers that prevent the successful implementation of clinical governance and conclude that the same problems occur time and again when any changes in practice are made. This applies equally to clinical supervision. The answer to resolving these problems in practice areas stems, according to McSherry and Pearce (2002), from a perceived lack of support from the organisation and the NHS Executive and Department of Health.
Support from outside the organisation can be provided through a number of agencies, including:
- The National Institute for Clinical Excellence;
- National service frameworks;
- The Commission for Health Improvement;
- The Modernisation Agency.
Internally, support can be provided through the use of clinical supervision that incorporates reflective practice, opportunities for lifelong learning, a competent appraisal system, and opportunities to carry out audit and network the findings. This can ensure that clinical supervision is part of clinical governance, focusing on the individual and his or her part in the framework.
To enable this to happen, the biggest change needs to be made in the NHS’ culture. Haslock (1999) describes the ideal organisation as one that is supportive, does not foster a culture of blame and has an educational atmosphere. It has a culture that promotes learning; learns from experience; disseminates information to everyone; allows for collaboration across all levels of the organisation; and rewards, values and develops staff.
Clinical governance provides a framework of continuous quality improvement, lifelong learning and continuing professional development that supports clinical supervision.
Quality improvement and lifelong learning can only be achieved by providing staff with support, resources and time to reflect on their experiences and practices. Investing in the development of a clinical supervision framework as part of clinical governance will ensure that individuals, teams and the organisation’s staff can develop and reflect, and improve their practice singly and collectively.