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Improving practice through a system of clinical supervision

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Health care organisations have a responsibility to ensure that their staff are sufficiently developed to enable practitioners to provide an appropriate standard of care (Clifton, 2002; Pritchard, 1997). Nurses need support in the development of their practice and one way of providing this support is through clinical supervision (Department of Health, 1993).

Abstract

VOL: 101, ISSUE: 23, PAGE NO: 30

Julie Robinson, RN, Dip HE Child, is staff nurse in paediatrics, Newcastle upon Tyne Hospitals, Sunderland

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Clinical supervision

Clinical supervision has been defined as ‘a process that promotes personal and professional development within a supportive relationship that is formed between equals’ (Butterworth and Faugier, 1994). Bond and Holland (1998) further define clinical supervision as ‘regular, protected time for facilitated, in-depth reflection on clinical practice. It aims to enable the supervisee to achieve, sustain and creatively develop a high quality of practice through the means of focused support and development’.

The concept of clinical supervision is not new. Most nurses will have encountered it at some stage in their careers. The benefits of clinical supervision are well documented (Box 1) and it could be argued that clinical supervision is an essential component of clinical governance. Despite this many nurses do not have access to regular supervision. In some areas this is due to misconceptions surrounding its purpose, while in others it is due to difficulties in implementation (Box 2).

Implementation

The staff on a busy paediatric ward sought to implement a sustained change in practice to ensure that staff were receiving regular supervision. Previous attempts at implementing clinical supervision on the ward had failed but the ward manger sought to overcome these problems by introducing the role of a clinical supervision facilitator. This role was undertaken by an existing member of the nursing team and was taken on in addition to the nurses clinical duties. The role was similar to that of a link nurse.

The purpose of the facilitator was to ease implementation and ensure a sustained change in practice. The facilitator and manager worked together with the manager overseeing the implementation and the facilitator acting as an agent of change.

Preparing for change

To help ensure a collaborative approach to change a junior member of staff was appointed to the facilitating role. This person required good leadership, problem-solving, communication and decision-making skills as well as a commitment to bringing about a change in practice. These are considered essential qualities if someone is to be an effective agent of change (Greenwood, 1997).

This strategy also helped to correct the common misconception that clinical supervision is a managerial function that is used to monitor performance, as the manager was not seen to be actively involved in facilitating the change.

Consultation

An initial review was undertaken to assess existing clinical supervision practice on the ward. A questionnaire was devised and sent to all staff to assess current views on the process and to establish whether any staff had had access to supervision either in the past or as part of an on-going supervisory relationship.

The staff were involved from the initiation stage. This was considered essential as staff co-operation is vital to the successful implementation of change.

The questionnaire identified that approximately one third of staff had experienced supervision with less than a third of these having regular supervision. Most staff understood the concept of supervision but saw the ward as being too busy and felt that this was why previous attempts at implementation had failed. Lack of time is also a commonly cited reason for not accessing supervision (Duarri and Kendrick, 1999).

Several nurses reported that they thought clinical supervision was unnecessary, suggesting that practitioners reflect with their colleagues on a daily basis, for example discussing concerns about a clinical incident over lunch. They thought that this served a useful cathartic purpose and that clinical supervision was an unnecessary formalisation of this.

While these informal discussions do serve an important purpose they do not allow for effective practice development. Clinical supervision is a process of professional support allowing reflection with the aim of identifying solutions to problems, improving practice and increasing awareness of professional issues.

Clinical supervision needs to be a formal process to ensure that the development of practice occurs (Department of Health, 1993; Kopp 2001).

During any change to practice some individuals will recognise the need for change while others will not. Therefore the facilitator attempted to raise the profile of clinical supervision (Box 3, page 32).

Staff were given the option of using group or one-to-one supervision, with the latter being the preferred method. It is important when introducing any change that staff are aware of the benefits. A guide, written by the facilitator, prepared staff to receive supervision and involved the staff in the change process therefore empowering them to be equal participants (Howatson-Jones, 2003).

Developing key skills

A literature review was undertaken to identify areas of best practice in relation to clinical supervision. This identified the desirable qualities of the clinical supervisor. The literature review revealed that an ideal standard would be educational preparation of nurses who are to undertake the role of clinical supervisor.

The Royal College of Nursing (1999) suggests that ‘training is necessary because there are definite skills involved in being a supervisor. No amount of enthusiasm, information or personal charm will allow them to do a good job without these skills’.

The trust did not offer a training programme for clinical supervisors, so experienced staff who had acted as mentors and preceptors were asked to volunteer as supervisors with the intention that training be arranged at a later date.

While the need for training was a long-term goal it was recognised that the nurses’ education and practice had already prepared the ground for them to communicate effectively with colleagues (Kopp, 2001). All supervisors were also to receive supervision. Other standards relating to the frequency and duration of meetings were formulated and a 30-45 minute session every four to six weeks was advised. This was also left open to individual negotiation between supervisor and supervisee.

Establishing supervisory relationships

Both supervisee and supervisor should have a degree of choice with whom they wish to enter a clinical supervisory relationship.

Choice is crucial to a meaningful supervisory relationship with the relationship being integral to the uptake and effectiveness of the whole supervision process (Howatson-Jones, 2003). For that reason supervisees were asked to choose two individuals from volunteer supervisors. These choices were forwarded to the facilitator who approached the supervisors and relationships were then established.

The facilitator was used to mediate between supervisee/supervisor so that if the supervisor did not want to act as a supervisor to a particular member of staff, then any embarrassment associated with rejection would be avoided. In some areas supervisors are allocated and this results in disempowerment both in the process of change and during the supervision.

Contracts

Once the relationships were agreed, contracts were drawn up. These form an essential part of establishing trust within the supervisory relationship and allow for ground rules including confidentiality to be set. Contracting is an important starting point for supervision in that it makes explicit the expectations of all parties avoiding later misunderstanding and enabling either party to withdraw from the relationship should they feel the need (Howatson-Jones, 2003).

Scheduling of sessions

Planning ahead was an essential requirement to ensure that regular sessions took place. This involved looking at the rota in advance to identify opportunities when both supervisor and supervisee were working together and scheduling in a session on that day. The facilitator undertook this role initially with the ward manager being instrumental in ensuring that there was adequate staffing on identified days.

Discussion

The process was reinforced during these initial stages by continuing to raise the profile of supervision through ward meetings and discussions. These allowed for the clarification of misconceptions and verbal autobiographical accounts regarding the benefits of supervision. Howatson-Jones (2003) has identified these as a useful means of overcoming difficulties in implementation.

Targets

During this transitional stage of change it was important that achievable targets were set and that the facilitator continued to act as a source of information regarding the process, informing staff during the process and ensuring their continuing agreement.

Having increased staff awareness and offering ongoing support in the early stages of implementation the sessions took place regularly. Autobiographical accounts and discussions proved invaluable. The facilitators’ role remained an integral part of the continuing process as it allowed the identification of any training needs and ongoing staff support.

Implications for practice

Implementing a system of clinical supervision requires time, commitment and enthusiasm. Those wanting to establish a system of supervision should consider introducing the role of a facilitator who can aid the implementation and raise the profile of clinical supervision.

Staff need to be kept fully informed throughout the process of change. Ward meetings can be used for this or facilitators may consider arranging a forum to give staff the opportunity to discuss concerns or raise queries regarding clinical supervision, allowing for myths and misconceptions to be clarified. 

Where possible training should be arranged and staff should have a degree of choice with whom they enter into a clinical supervisory relationship. Planning ahead during the early stages is important in ensuring success. This includes looking at staffing rotas in advance to ensure adequate staffing on days when sessions are planned.

Conclusion

The benefits of clinical supervision, including professional growth and development and better outcomes for patients have been well documented. However, due to difficulties in implementation, such as lack of time and inadequate preparation, the provision of effective clinical supervision is often neglected. It is hoped that introducing the role of clinical supervision facilitator will better enable health care organisations to provide the support that nurses need.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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