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Changing practice

Clinical supervision using the 4S model 2: training supervisors to deliver effective sessions 

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Supervisors must be properly prepared if they are to deliver effective supervision. A solution focused approach to their training ensures they have the right skills

 

Author

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.

Abstract

Waskett C (2010) Clinical supervision using the 4S model 2: training supervisors to deliver effective sessions. Nursing Times; 106: 17, early online publication.

This second in a three part series on the 4S model of clinical supervision examines in house training for supervisors. Part 1 discussed how trusts can prepare for a clinical supervision scheme. The final part describes essential support for supervisors and the process of sustainability. The three articles together comprise the 4S model of organisational supervision (Waskett, 2009a).

Keywords Clinical supervision, 4S model, Training, Supervisors, Skills

  • This article has been double-blind peer reviewed

 

 

Practice points

  • A two day training course for up to 20 participants can be highly effective.
  • A solution focused approach is simple, disciplined and appropriate for healthcare professionals.
  • Local policy and protocols should be provided for trainers and course participants.
  • Practical organisational processes are as crucial as the “how to” of supervision.

 

Introduction

The work of every professional benefits from time set aside for focused reflection and consideration of their practice and how they can improve it, whether this is done in small groups or with one person. Supportive clinical supervision is an ideal way to benefit staff wellbeing, and is advocated by the Department of Health and professional bodies (Waskett, 2010).

A good way to provide supervision across trusts is to prepare practitioners to offer it to other staff, giving them protected time and some brief, simple yet disciplined training in a specific model. Training in “general” supervision, or an overview of several approaches, can be vague, and tends to result in participants leaving with ideas about paperwork or a few different theories, but no clear practical ideas about how to do the job. It is better to train well using one approach. This article explores how clinical supervisors can be trained in house in two days, using a solution focused approach. Ideally, the lead managers will have already prepared the systemic framework and policy that enables new supervisors to work effectively (part 1), and will have in hand the processes that follow supervisor training and sustain practice (part 3).

Setting up training

Trusts should take responsibility for planning supervisor training, taking care of the usual essential administration and processing of applications; arranging a suitable spacious venue (bearing in mind that training entails much pairs/group work and moving around); and organising refreshments.

The lead group will already have decided how to plan the intervals between training sessions, depending on how many staff will eventually need supervision and therefore how many trained supervisors will be needed in what timescale (part 1). Service requirements will inevitably play a part in this, such as:

  • How many staff can managers and team leaders spare for two days at particular times of the year?
  • Who will facilitate and run the training courses?
  • Does the trust employ or know someone who is well versed in the solution focused approach, familiar with both group and individual supervision issues, and who can handle interactive training comfortably?

A confident, practical and welcoming trainer who designs and carries out a smoothly run two days makes all the difference to how participants go on to use their new skills - like all courses, this should be coupled irrevocably to later practice.  

Who should attend training?

This depends on previous decisions made by the lead group (part 1). It is likely there will be three categories of attendees: staff who want to learn how to supervise; those who have had training in the past and want to refresh their learning; and managers with an interest. This last category should not be neglected; great benefits can come from having senior managers understand the approach and the views of other staff. Even if the managers do not intend to do direct supervision, they are still likely to be able to use the approach in their work.

Groups of trainees should be kept quite small – 8-20 is ideal - as the course is highly interactive involving much discussion. A small amount of reading before training can prepare participants for this new approach, and information packs should be ready for each person. If possible the pack should include a copy of the trust’s supervision policy and other protocols. Table 1 outlines the next stages in setting up a clinical supervision scheme, relating to parts 2 and 3 of this series.

A two day solution focused supervision course

The course should be welcoming, informal and interactive, preferably using accelerated learning techniques (Meier, 2000) to accommodate the participants’ varied learning preferences and stimulate everyone’s interest. The facilitator should naturally model the solution focused approach by discovering the group’s best hopes for the course, appreciating their existing strengths and abilities, and creating many opportunities for all participants to explore and make progress towards the best they can be as a learner and, ultimately, supervisor. The trainer should introduce new material in a way that invites participants to debate, explore and practise at every step, thus building confidence. Throughout the course, the “double vision” that supervisors need is highlighted, whereby they look for strengths, expertise and growing points in both supervisees and the patient, client or professional situation being discussed. We also work towards helping supervisors to reflect on their own behaviours, not only noticing, working with and describing their supervisees’ issues, but also observing and reflecting on their own practice in the role.

The solution focused approach

This approach is recommended as it is a clear, simple and respectful model with a strong background. Both individual and group supervision using this model are well described in the literature. For background understanding, Macdonald (2007) laid out the entire approach from antecedents to research results, with a useful if brief section on supervision. O’Connell and Jones (1997), in a succinct and still extremely relevant article, looked specifically at supervision using this approach, summarising it as follows:

”SF [solution focused] supervision validates the competence and resources of the supervisee, emphasises the importance of clear incremental goals and identifies pre-existing solutions and exceptions to problems in the supervisee’s work.”

Thomas (1996) provided useful insights on the philosophical and theoretical background to the model, and emphasised supervisors’ accepting and enabling position of appreciating the abilities and resources of supervisees and building on these together. The article’s title, “the coaxing of expertise”, describes this approach in a nutshell.

While writers on the solution focused approach mainly tend to discuss supervision for psychotherapists, the model is easily shifted to other professionals. Some have already written on the topic - for example, Burns (2005) described using it with speech and language therapists. She cited a typical supervision question which illustrates the future oriented, resourceful way in which the approach works: how will you and your colleagues know when you are doing your job especially well, and in which ways is this already happening?

Duncan et al (2007) discussed use of the solution focused approach in mental health occupational therapy continuing professional development. This included some useful forms aiding forward planning, which could also be used for supervision.

I have previously discussed transferring this model of supervision into health and social care (Waskett, 2009a; 2009b; 2006).

A valuable side effect of using this model is that the skills are also applicable to other areas including clinical and managerial work and team leadership; participants on every training course mention this, and some even experiment with taking it home for domestic use.

Although it is appreciative and respectful, solution focused supervision is not “soft”. The supervisor, as in all approaches, retains responsibility for being aware of problematic areas, and in the rare circumstances of a supervisee being involved in malpractice or other risky behaviour, certain steps must be taken; these are explored in training. Nevertheless, people who are trusted and appreciated are more likely to work with their supervisor to take the right decisions to improve their practice, or, in worst case scenarios, to inform management or take other steps towards restoration; it is the supervisor’s responsibility to ensure this happens.

Course content

Courses should be designed and run with the local organisational supervision policy at hand and with local conditions in mind. Their content will depend on the way the facilitator designs it, but should first aim to ensure participants understand what supervision is. Even at this stage, participants are often confused about this, and can muddle supervision with line management, mentoring, coaching, performance management, appraisals, team meetings and a myriad of other practices. It is therefore worth ensuring that everyone understands the purpose of the process - to establish non management relationships which facilitate professionals to work better, by helping them to explore their own practice and reach for (even) greater excellence. Good supportive supervision should be career long, and run alongside (not instead of) regular line management and any other staff monitoring and development.

A large proportion of training time will be given to teaching some of the basic solution focused language skills that supervisors can use to help individuals or groups explore issues raised in supervision.  Boundary issues and grey ethical areas can also be understood by using exercises such as scenarios.

This is not the kind of course where the trainer remains at the front with a PowerPoint presentation. It is less about giving information than enabling participants to absorb and practise the way the solution focused approach works effectively within the ethical boundaries of good supervision, taking into account local organisational constraints and guidelines. The course will vary according to the management group’s earlier decisions. Box 1 outlines the essentials of solution focused supervisor training.

 

Box 1. Essentials of training

  • Definition of solution focused clinical supervision - supportive, curious, “coaxing expertise”
  • Four basic solution focused language skills
  • Boundary and ethical issues, such as confidentiality
  • Next small, practical steps for supervisors
  • Appreciative, interactive, experiential training

 

Training for group work

If it has been decided that supervision will be carried out in small groups, a substantial proportion of time must be devoted to teaching about groups and running “live” groups in the classroom. Group supervision in the past has sometimes gained a reputation for degenerating into a “gossip session” or worse - this wastes precious time and energy. The solution focused approach provides a disciplined and positive way of moving towards what supervisees want from their supervision, rather than what they do not want, so it bypasses any opportunities for gossip by focusing on supervisees’ goals, hopes and aspirations for professional practice.

In starting a new group, the supervisor invites members to introduce themselves and say something about how they would like the group to be useful to their practice. The supervisor asks how they want to use the time effectively and how they will know they are getting what they want. Establishing group goals means that later, the group can assess whether these are being met and if not, what needs to be amended. With the supervisor’s attention and encouragement, members take responsibility for getting what they want both as individuals and as a group. They develop ground rules, for example, on how group confidentiality will work or whether interrupting each other is acceptable.

When a group is established and working well, trust in each other will grow, together with a sense of freedom to explore issues which previously may only have been thought about alone, perhaps in the car on the way home from work.

A typical group member is Carrie (not her real name), a specialist nurse with high standards for herself, who had never had supervision in the past. Her account of the difficulties of working with a particular patient with mental health problems, together with her sense of shame that she felt she was not offering him what was needed, induced an overwhelmingly supportive reaction from other members. With the supervisor’s help they were also able to give Carrie quiet space to talk, think and express herself. By the end of her supervision time, Carrie was able to think of creative and respectful ways in which she might put down clearer boundaries for the patient, thus taking care of both him and herself. Using this model, it is never mandatory to “report back” (at eight weekly intervals or more, many issues have been dealt with and gone by the time the next session arrives). But Carrie did in fact choose to revisit this issue and said that both she and the patient had been relieved and comforted by her new confidence and boundary setting. He had now been discharged - something, Carrie said, that may well not have happened otherwise, as she would have been too anxious to “let her patient go”.

Groups need to remain consistent for at least four sessions with the same people; aided by the supervisor, groups are “owned” by participants who develop their own goals and measure their own progress as they continue. There may be times when the group is opened to admit more members or even re-form, although a top limit of eight members is advised.

In training it is helpful to teach the group process described by Sharry (2007) and Norman (2003), so that supervisors can go on to use this in group supervision. This is a disciplined and positive process in which members take turns to ask questions of the person presenting an issue, in a series of rounds. A member can move through the entire process of presenting a case and receiving feedback on it in 20 minutes, finishing with their own feedback to the group about what has been helpful in what has been said, and what they intend to do next. Adopting this method keeps the group working on progress and learning. It is easily taught experientially, and appears very acceptable to most groups.

Throughout training it is worthwhile to facilitate a great deal of practice, which means the group will form and re-form in pairs and groups, giving feedback to each other and often to the whole group. Although the experience is usually enjoyable for participants, they are learning rapidly, and so the trainer needs to remember to build in plenty of breaks and peripheral activities to vary the pace, as well as helping people to revisit and extend their learning in different ways.

Everything taught on the course is aimed at ensuring supervisors have the basic understanding and skills to practise effectively, ethically and safely - though naturally they will make mistakes and learn from them out in the “real world”.

Finishing the course

Towards the end of the course, participants will look outward to “real life” and this is where the trust’s policy and other protocol documents become valuable. Questions will surface: when will these new supervisors begin to practise? How do they handle the first meeting with supervisees? Are the supervisors’ line managers alerted to and happy about the fact they will be doing supervision regularly? What paperwork will supervisors need to complete when they see an individual or group? Who will book the venue for supervision? Will the effects of supervision be evaluated? How many supervisees or groups are new supervisors expected to take on at once? What if something goes wrong or a supervisor feels out of their depth - where can they go to for advice? When will all the supervisors meet again? The trainer’s (and participants’) life will be made much easier if the lead management group has already thought through some of these questions.

Ideally each new supervisor will leave the course with a reasonably clear idea about how they will go about the next steps of moving their new supervision skills into real life practice. That link between the course and the ongoing routine activity of supervision is an important key to making the scheme work for the future. Care and development of these new supervisors, as well as work on sustainability, will ensure that supportive clinical supervision becomes an accepted, routine and valued part of the trust.

  • Part 3 of this series, to be published in next week’s issue, examines support for supervisors and how to sustain supervision

 

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