After training, supervisors need ongoing support to enable them to deliver effective supervision. It is vital to plan how to sustain supervision schemes
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 3: how to support supervisors and sustain schemes. Nursing Times; 106: 17, early online publication.
This final article in a three part series on establishing clinical supervision discusses essential support for supervisors after training, and how to sustain supervision schemes, including issues such as evaluation and ongoing training.
Part 1 examined the initial structural arrangements and policy development, while part 2 described training for supervisors.
Keywords Clinical supervision, 4S model, Support, Sustainability
This article has been double-blind peer reviewed
- Preparation ensures that new supervisors have supervisees to work with.
- Regular support and development for trained supervisors is essential.
- The scheme should have time to mature before “train the trainer” courses are organised.
- Evaluation will show whether trusts have a return on their investment.
Having invested to establish a good supervision scheme, there should be lasting benefit, enabling supportive supervision to become a regular, robust and beneficial part of a trust’s life, its practitioners and stakeholders. The previous parts of this series discussed the first two phases of incorporating clinical supervision into trusts - the systemic structure (Waskett, 2010a) and teaching supervision skills (Waskett, 2010b).
The next phase of work falls into two sections. The first is to support supervisors who have been trained, so their skills are welcomed and become useful to the trust, and their abilities to do so are nurtured and continuously developed. The second part is to lay plans for the whole project’s sustainability. The aim is to maintain an evolving, enthusiastic, competent cohort of supervisors who support colleagues regularly and effectively.
Practitioners finishing training are likely to be enthusiastic and eager to use their new skills and understanding to support colleagues. Being able to carry out supervision soon after training, and regularly thereafter, will build their confidence and continue the process of learning by practice. The first level of support is therefore to ensure that staff who want supervision are able to contact supervisors for either one to one or group sessions, and that these can begin as soon as possible after training.
Developing any new skill involves making mistakes – which can also be seen as learning opportunities. Supervisors often worry, quite reasonably, that they have not learnt enough or become expert enough on the two day course. However, the real expertise develops as they relax, learn and realise they do not have to have the answers for supervisees, while still upholding the ethical responsibility inherent in the role. Supervisors are therefore encouraged to be transparent with supervisees about their developing abilities as well as their uncertainties, so both groups can learn together and develop what works in practice as time goes by.
Facilitating supervision soon after the end of training will depend on some of the lead group’s work before the courses (Waskett, 2010a). They will have:
- Agreed that the trust will offer either group or one to one supervision, or both;
- Raised practitioners’ awareness so they know that trained supervisors will soon be available and how to contact them;
- Ensured that managers and team leaders are aware of the imminent change and understand what supervision is (compared with line management or mentoring); that the trust has approved it; and that middle managers are expected to allow their staff to take the protected time outlined in the policy.
The lead group should be prepared to keep the issue in high profile throughout the trust for some time; the bridge between trainee supervisors finishing training and allowing them to start practising is crucial. It should be clear to both supervisors and potential supervisees exactly how the structure works - how a group is formed, when and where they meet, or how an individual supervisee can contact a supervisor and what happens next. Some of this responsibility may fall on supervisors’ shoulders - if so, this should be clear.
Other parts of the system should be woven into the scheme: for instance, a question could be built into appraisal about whether appraisees are using supervision or practising it. Alongside this, the skills of both offering and receiving supervision can be mapped onto the Knowledge and Skills Framework (KSF) (Department of Health, 2004) so that such skills can be added to individual portfolios (Table 1). Once staff begin to connect all this up and work together, new supervisors will grow in their abilities and supervisees will begin to benefit. Better practice will result and as time goes by, the trust will begin to profit. Maintaining a systemic view of the whole issue throughout the trust is important.
The supervisor’s supervisor
Once practice has begun, supervisors will be doing something stimulating and different from their usual work. To make the most of learning from these experiences, they will need to do some active reflection. Maintaining supervisees’ confidentiality is crucial in the supervision relationship, so care must be taken with this. Each supervisor should have their own supervisor, to whom anything can be expressed in the certainty that it goes no further. Again, this may be one to one supervision or a group of peer supervisors. Supervisees’ names should not be disclosed in this supervision, and every effort should be made to protect their confidentiality. Supervisors should be able to discuss their everyday clinical work as well as their supervision work in supervision. If possible, trusts should ensure someone is available to act as a “backstop”, available to consult confidentially on any acute supervision issues new supervisors may need help with. While this may be rarely used, it gives a sense of security. Bor and Miller (1991) provided a helpful outline of the way such a person might go about consultation.
Regular supervisor meetings
In training, groups frequently express the hope that they can meet together again, and many say that being able to discuss supervision issues with others in the course is invaluable. Sometimes supervisors express concern that once the course is finished, they will be “out there” on their own. If they receive their own supervision in a peer group of up to eight members, this will be taken care of to some extent. Nevertheless, a supervision group is a small group with a specific function which does not include top up training, discussing practical arrangements surrounding supervision, and similar matters.
This gap may be filled by arranging for all supervisors in the trust to be invited to a support group twice a year, where they can benefit from the larger pool of practising supervisors and arrange the agenda according to their needs. The original trainer could facilitate this group at first, although eventually supervisors will take responsibility for this and become self sufficient. The group may decide to have an overview of the whole scheme. Problems always occur in any scheme and it may be necessary to adapt or innovate to keep it running smoothly; either supervisors themselves may do this, or they may pass on their recommendations to the lead management group. They could also, if they wish, use this time for refresher training.
Discussion and reading
In some trusts it may be possible to set up an online discussion group where supervisors can share ideas, successes and dilemmas, reading and other ways to maintain interest and learning. The solution focused model is easy to learn, but takes practice and discipline to maintain and progress in. It is all too easy to let supervision conversations slip and revert to a familiar problem oriented way of talking, particularly as supervisees in the health service will initially expect this. However, awareness raising and the first few sessions of supervision will help supervisees to tune into the general stance of this approach and begin to take more responsibility for their own decision making.
The other temptation is to revert to the familiar didactic position. A psychoanalyst described the great temptation for a member of his profession to become “the magician”, and this also applies to supervisors’ role:
“The patient [supervisee] often looks to the psychotherapist [supervisor] not only for effective support in the fight against neurosis [e.g. blind spots, risk, incompetence etc], but also for access to secret knowledge which will find a solution to all of life’s [one’s patients’] problems.” (Guggenbuhl-Craig, 2004).
Most healthcare practitioners have been trained in the medical model in which advice is given and problems are fixed (if possible). Conversely, in the solution focused approach, the skill lies in making space and facilitating the other person to think for themselves. To maintain the supervisor’s curiosity about and faith in the supervisee, it is essential to maintain their own self awareness and learning, perhaps by talking to others using the same approach, reading, maybe attending conferences or joining an organisation (such as the United Kingdom Association for Solution Focused Practice, see www.ukasfp.co.uk).
While the material discussed in supervision is, of course, confidential, the skills required to be either a supervisee or supervisor can be mapped onto the KSF core dimensions and used in Agenda for Change job outlines, appraisals and portfolios. Table 1 briefly suggests how these connect for the supervisor’s role.
Newly trained supervisors should steadily become more competent, adaptable, confident and effective in their supervision work, through adequate supervision, either one to one or group, twice yearly gatherings of all supervisors, and managerial encouragement to reflect, read and discuss the craft of supervision on an ongoing basis, including mapping these skills onto the KSF dimensions.
Box 1 outlines key points on supporting supervisors.
Box 1. Supporting supervisors
- Enable regular practice as soon as possible after training.
- Ensure all supervisors have their own supervision.
- Link supervision to other parts of the system (such as Agenda for Change activities).
- Set up twice yearly supervisor meetings.
Hawkins and Shohet (2003) were right to state:
“Supervision is likely to be established in a more sustainable way if the whole organisational process is carefully designed and monitored.”
This is the part that is so often neglected, as the final “S” - sustainability - in the 4S model is probably the most difficult to pin down. In the constant turmoil of changes imposed on the health service from within trusts and (politically) from outside, it is challenging to consistently maintain and improve a practice that supports staff, year after year. In addition, thinking of supervision as part of a wider culture of systemic supportive activities is unusual. The literature tends to have a narrow focus on supervision practice, relationship dynamics, group working, evaluation and so forth - the “how to” of supervision itself. This narrow view may echo the understandable culture of individual pathology in the NHS, which has in the past been paralleled by supervision (where it exists), focusing on individual supervisee pathology and “difficulties” rather than systemic, positive support and encouragement. It is the processes, systems and structures of enabling supervision and other supportive activities within the trust’s culture that enables supervision to work and take hold in the long run.
Hawkins and Shohet (2003) introduced and expanded on systemic ideas, pointing out the beneficial connections between supervision and learning. They suggested many other activities which, together with regular supervision, facilitate the learning organisation, such as:
- The culture of learning and development itself;
- A no blame, appreciative culture;
- Well balanced teams and departments;
- Team development sessions;
- Well managed inductions and other transitions and appraisals.
Hawkins and Shohet’s (2003) penultimate chapter looks briefly at the development of policy and practice, and all managers intending to establish their own supervision schemes should read it.
When trusts invest time and money in an activity such as supervision, they need to know they have a return on their investment. While the practice may satisfy the demands of professional bodies and demonstrate to outsiders that staff are cared for, there are many other questions of interest to those responsible for spending taxpayers’ money. Does it make a difference to the following: Staff morale? Patient care? Reflective practice? Risk issues? Recruitment, retention and sickness rates? Staff relationships and collaborative team working? Cross agency working? Supervisors and supervisees will also want to know that what they are doing is “working”. Attending a group or a one to one session must be helpful and progressive for professional practice in some way, and staff will be reassured to know this is being monitored and evaluated.
Ideally, the lead managers will have already thought about what they need to know later to show them that supervision is worthwhile. Some baseline measurements may have been taken at an early stage for later comparison. An in house research tool could be developed and a timescale agreed. Alternatively, an externally developed and validated tool such as the Manchester Clinical Supervision Scale (available via Osman Consulting at tinyurl.com/manchester-scale) could be used. It would be wise to leave some time (say, two years) for the scheme to mature and for the first tranche of supervisors to develop confidence and skills before assessment and final evaluation. This should show whether the activity is worth doing, what amendments might need to be put in place, and whether clinical supervision should be continued. Box 2 outlines key points on sustaining supervision.
Box 2. Sustainability
- Supervision should be career long, regular and routine.
- Evaluation means everyone involved knows if the activity is worthwhile, and what needs adjusting.
- A positive, appreciative feedback culture will support staff and patients best.
As supervisors grow in skills and confidence, with support and practice, they will also consider how supervision can continue. Staff members are promoted, retire or leave, so there will always be a need for new generations of supervisors. The traditional health service “see one, do one, teach one” orthodoxy has created an almost cavalier approach to skilled activity, and it can be tempting to throw new supervisors into teaching others with barely a pause to build up any experience. Doing this is unfair on supervisors, and would degrade the teaching of the next generation and therefore the whole practice of supervision itself. Teaching others the skills of supervision requires substantial experience in both teaching and supervision.
The first cohorts of supervisors often include experienced teachers and trainers, and after at least a year’s experience in practice, these may be the first to volunteer to train the next generation. “Train the trainer” courses can offer materials and help staff develop their own ideas about the most important elements of supervision skills and how to enable trainees to learn them. These trainers will develop the most effective and lively courses from (again) plenty of experience of teaching, aided by feedback from participants. At the same time, awareness raising for new supervisees should not be neglected; supervisors may be able to take some of this on too. Steadily, the entire scheme becomes self supporting in house, and further generations of supervisors and supervisees are assured.
Bor R, Miller R (1991) Internal Consultation in Health Care Settings. London: Karnac Books.
Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. London: DH.
Guggenbuhl-Craig A (2004) Power in the Helping Professions. Putnam, Connecticut: Spring Publications Inc.
Hawkins P, Shohet R (2003) Supervision in the Helping Professions. Maidenhead: Open University Press.
Waskett C (2010a) Clinical supervision using the 4S model 1: considering the structure and setting it up. Nursing Times; 106: 16, early online publication.
Waskett C (2010b) Clinical supervision using the 4S model 2: training supervisors to deliver effective sessions.Nursing Times; 106: 17, early online publication.