VOL: 98, ISSUE: 09, PAGE NO: 36
Elizabeth Clifton, BSc, SRN, NDNCert, is project manager, Dudley Priority Health NHS Trust
Clinical supervision is a formal process of professional support and learning that addresses practitioners’ developmental needs in a non-judgemental way. Its aim is to help them increase both their competence and confidence through exchanges with experienced professionals and the use of reflective skills (Butterworth, 1992).
The concept of supervision has been a part of health and social care professionals’ roles for some time. For example, midwifery and social work have established supervision systems that monitor, enhance and develop practice. However, it must also be acknowledged that some of these systems are inextricably linked to management structures, a factor that can work against open and frank discussion.
The concept of clinical supervision is founded on a number of assumptions:
- Knowledge and skills must continue to expand throughout an individual’s career if that person is to be enabled to meet the complex demands of modern health care;
- Reflecting on actions during or after practice can lead to a deeper understanding of patients’ needs, and subsequently to personal and professional development;
- Modern health care practice places unprecedented demands on staff so nurses need help in dealing with these demands to prevent burnout;
- Health care organisations have a responsibility to ensure that their workforces are sufficiently developed to enable practitioners to provide an appropriate standard of service. Clinical supervision must be regarded as a part of clinical governance that emphasises the importance of improving patient care and maintaining high standards of service and clinical delivery (Department of Health, 1998). A report on primary care (NHS Executive, 2000) suggests that clinical supervision is one way in which trusts might seek to promote clinical effectiveness and form a responsive culture.
In 1999, the director of nursing at Dudley Priority Health NHS Trust initiated a project to implement clinical supervision across all disciplines. The trust provides services for people with learning disabilities and mental health problems, and those who require community care. It employs 745 nurses and 269 other health care professionals, including physiotherapists, occupational therapists, psychologists and speech and language therapists.
Background to the project
The clinical governance department acted as the focal point for the project because of its trust-wide remit and influence. It provided a base and support for staff leading the clinical supervision initiative, resources such as information technology and computer access, and links with higher education.
Two community nurses, one from learning disabilities and one from district nursing, were seconded to the department to lead the initiative for six months. The learning disabilities nurse worked full-time and was seconded for two days a week, and the district nurse worked four days a week and was seconded for all four days. These nurses were selected because both had researched clinical supervision as part of their degree studies and had an interest in implementing their ideas.
The project lead nurses’ research showed that some groups of staff in the trust, such as occupational therapy and learning disabilities, had established systems of supervision, while others were lagging behind and seemed threatened by the idea.
Resistance to clinical supervision has been noted elsewhere. Cutliffe and Proctor (1998) attributed it to management cultures that discouraged the expression of emotion, perceptions of clinical supervision as a form of therapy and a general lack of clarity regarding its purpose. The research done by the lead nurses highlighted the importance of convincing all practitioners that they would benefit from clinical supervision.
Outline of the project
The lead nurses developed a strategy for implementing clinical supervision across the trust. This is described in four stages, although the stages tended to overlap and several aspects of the project took place concurrently rather than consecutively.
The first task was to raise awareness of clinical supervision across the trust, so a survey was carried out to find out what practitioners thought about it. Awareness sessions were also set up. These involved the district nurse meeting as many community nurses in the trust as possible. The purpose of these meetings was to provide information and exchange views and opinions. Communication was aided by the trust’s weekly staff bulletin.
A ‘bottom-up’ strategy for change was planned. According to Wright (1998), this is one way of introducing change with maximum benefit for all concerned. It involves identifying five factors:
1. Who will do what? The two lead nurses provided leadership for the development of clinical supervision. Part of this role was to ensure the active participation of practitioners.
2. Why is this necessary? Leadership is ‘a process of moving the self and others towards a shared vision’ (Malone, 1996). Inherent in the process of bringing about the vision (in this case, introducing clinical supervision) is the concept of change. Introducing change involves some element of risk. For example, some staff groups had no tradition of clinical supervision and could have rejected the idea outright. Effective leadership involves helping people to overcome their misgivings and try out new ideas (Malone, 1996).
3. How will this be achieved? The lead nurses addressed the organisation as a whole, involving all staff groups in a multidisciplinary steering group for the implementation of clinical supervision. Managers and heads of service were involved in the change process as their support and commitment were crucial to the project’s success. It is important that all stakeholders feel that they are involved and consulted throughout a period of change.
The most important factor in bottom-up change is the participation of clinicians. This ensures that the change moves up through the rest of the organisation. The challenge was to convince all clinicians that clinical supervision would benefit them and to encourage them to adopt it.
4. Where would the change take place? Should all staff groups be included?
5. When would the implementation start and over what timescale?
The steering group identified a lack of expertise in the trust on preparing staff to conduct clinical supervision. Training was commissioned from an external company selected because it encouraged an organisation-wide approach to both training and implementation. Funding for the training and stage four was obtained from the Black Country Education and Training Consortium.
The company ran a three-day training course in conducting clinical supervision across all disciplines for those who were to act as supervisors. This covered issues such as:
- A definition of clinical supervision;
- Models and frameworks of supervision;
- Setting up a supervision agreement;
- Challenging poor performance;
Staff had the opportunity to rehearse skills during the three-day course and were asked to attend with a supervision partner or ‘buddy’. The buddy system was used as a way to ensure that staff had ongoing support after completing the training.
Eight members of staff were identified as willing and able to take responsibility for future training in clinical supervision. They included a continence adviser, and representatives from district nursing, health visiting, occupational therapy, learning disabilities and the professional development unit. These eight had a further 15 days’ training which focused on putting the themes of the three-day programme into practice. They were required to observe the trainer, take notes and then move from presenting part of the programme to presenting the whole programme with another trainer.
It is hoped that by April this year, 80% of eligible staff will have completed the three-day course.
A small multidisciplinary project team, including staff from mental health, physiotherapy, learning disabilities, occupational therapy, district nursing, health visiting and the professional development unit, evolved from the larger steering group. Its aim was to continue the development of clinical supervision across the trust. So far the team has:
- Presented a paper to the trust board outlining the work done, the benefits obtained and those anticipated for the future;
- Made a presentation to the executive management team outlining the progress made and seeking support for continued implementation;
- Produced a draft policy on clinical supervision to be presented to the executive management team. This sets out the principles of the trust’s policy and the aims of the implementation and development of clinical supervision;
- Worked closely with the human resources department to ensure that clinical supervision is integrated into personal development plans. All clinicians working in the trust will have a personal and team development plan;
- Developed a manual on clinical supervision which will be given to staff taking the three-day course. Clinicians can use the manual during training to reinforce key stages of the supervision model and as a reference after training.
The project owes its success to a number of factors. Members of the project team and the trainers came from a variety of clinical backgrounds, so they were able to keep their managers and staff informed and up to date, and to consult with them when required, improving multidisciplinary working.
The bottom-up approach involved participation at practitioner level, which helped staff to feel a degree of ownership and control during the implementation process. And the early development of a team of eight trainers created a valuable resource. Many also work on the project team and support the implementation of supervision in their own disciplines.
The involvement of senior managers ensured that they also promoted clinical supervision among their staff. Managerial commitment to clinical supervision enables clinicians to allow themselves the time and space to develop and enhance their practice.
Finally, the grant from the Black Country Education and Training Consortium provided the resources we needed to launch the project.
The way forward
Although the project has been a success, a number of challenges need to be met to ensure that it continues. The lead nurses found it difficult to fulfil all their commitments, particularly when their secondments ended. A ‘champion’ is needed to ensure the continuing leadership for the project. The absence of someone to steer or lead the process of implementation at team and organisational level often means that progress slows down (NHS Executive, 2000).
To maintain momentum and a high profile for clinical supervision throughout the trust, it is essential to continue to ‘sell’ the concept of clinical supervision to staff and managers, despite the severe time pressures that all clinicians are under because of increasing workloads. The project team and the training programme need to be managed and must have the necessary administrative support to be effective.