What is clinical supervision and how can it be delivered in practice?

Introduction

Clinical supervision is a formal process of professional support, reflection and learning that contributes to individual development. All nurses work with people who are likely to be in physical and/or psychological pain – this can create a demand and put pressure on nurses that can be both testing and cumulative. Clinical supervision can offer support to new and experienced health professionals alike in their daily work.

Origins of clinical supervision

Clinical supervision is nothing new and has been used for many years in a range of disciplines across the healthcare field but, for nurses and midwives, it began in earnest in the 1990s. The publication of a first clinical supervision textbook for nurses in the UK in 1992, since updated (Butterworth et al, 2001), was followed by a series of articles and surveys over the next two decades, looking at the benefits and difficulties of implementing clinical supervision. In 1996, in a Department of Health funded review on the usefulness of clinical supervision, Butterworth et al (1996) suggested that it clearly added value, and several textbooks and many review articles have followed since then, adding to the debate.

Clinical supervision was embraced quickly by nurses in mental health settings. However, it was less widely adopted in general nursing care, where there was reluctance to engage, perhaps because of time pressures, and lack of opportunity and suitable expertise of supervisors. A continued debate on individuals’ and organisations’ poor uptake of clinical supervision has continued, but uptake is unlikely to improve without some policy initiatives to move matters onwards.

New policy imperatives, such as the preparation and designation of professional nurse advocates, are likely to improve the situation dramatically (May, 2021). An extensive roll-out of nurse advocate courses is under way in England, and a key element of the courses is preparing nurses and midwives to be supervisors. Evaluation data from these courses will help in the development of clinical supervision that best fits the profession. A growth in the Advocating for Education and Quality Improvement (A-EQUIP) model of supervision for midwives has seen wide adoption of a more refined and refreshed supervision provision for midwives across England.

Supervision has long been used more extensively in mental health settings, but the renewed ‘policy push’ should help with a more widespread adoption (Dunkley-Bent, 2017). The need to enhance the quality of clinical supervision, outlined by Driscoll (2019), is being increasingly recognised and this will add to the demands on the profession and employers alike. Several nursing charities are rolling out courses that will give nurses the opportunity to engage with clinical supervision. One such charity is the Foundation of Nursing Studies, which is developing an extensive programme of resilience-based clinical supervision courses.

Types of clinical supervision

Theoretical underpinnings

Yegditch (1998) observed on clinical supervision in Australia that, “The most problematic issue surrounding the contemporary idea of clinical supervision in nursing both here and overseas, concerns what it actually is – and how it will be articulated, refined and implemented”. This is just as true today and some of the literature is still wrestling with this conundrum; however, this should not paralyse progress.

The use of clinical supervision is most commonly practised in counselling and psychodynamic psychotherapy, and can also be found in behavioral therapy. These will have a particular approach based on their theoretical backgrounds. The model of supervision adopted by nurses has often been that posited by Brigid Proctor (Proctor, 2010): she offers an approach through a core of normative, formative and restorative elements.

Proctor has a background outside of the health sector, and has warned about adopting her model without thinking carefully about its appropriateness: “I cannot stress enough that I believe health practitioners – and indeed each group of professionals – need to develop supervision training, models and skills which are immediately useful and practicable in their own context, within professionally agreed tasks and responsibilities” (Proctor, 2001).

Wise words indeed. As nursing and midwifery develop our own ways of working with clinical supervision, the most appropriate theoretical underpinnings will emerge more clearly. In the meantime, there is still value in using and testing the approaches taken by others where appropriate. Influences from psychodynamic therapy are likely to be comfortable for mental health nurses but are perhaps less so for those in general nursing, who may favour those that are used in counselling or education.

We will undoubtedly eventually arrive at useful and commonly understood definitions for nurses. In the current enthusiasm for resilience-based clinical supervision, we see the emergence of a strand of work that is both useful and helpful, but cautions abound as we seek to support people in practice. In inexperienced hands, it is possible to push resilience too far. As Mahdiani (2021) suggests, it is also important to reflect on the “dark side” of resilience and consider whether there is too much emphasis on being strong and resilient at the expense of other considerations about the individual practitioner.

The present circumstances facing healthcare are truly difficult. The workforce is under stress as never before and the ‘weathering’ of staff under constant work pressures, staff shortages, poor healthcare funding and unprecedented demand, exacerbated by the Covid-19 pandemic, means the sector needs as much support as can be given. Clinical supervision has a positive contribution to make by supporting staff in such troubled times.

“It is also important to reflect on the ‘dark side’ of resilience and consider whether there is too much emphasis on being strong and resilient at the expense of other considerations”

Methods of delivery

Often local circumstances will determine delivery methods in clinical supervision. As an example, opportunities in acute emergency care will be different from those in community nursing; as such, the delivery of clinical supervision will depend on the setting and the organisation. Three possibilities are offered below.

One-to-one supervision
Traditionally – and, perhaps, ideally – supervision has been offered on a one-to-one basis with an expert professional from a nurse’s specific field or specialty. Supervisors will have been properly prepared for this role and can offer sufficient time and opportunity to the supervisee. Sadly, this is not always possible and other methods are needed. This is not to suggest the ‘ideal’ should not be pursued but indicates that it may not always be viable. Other professions can help.

Clinical psychologists are often keen to offer support through clinical supervision, but it is likely to be through their own professional and educational frames of reference, not those of the nurses they seek to support. Nonetheless, it may be better than having no support at all.

Group supervision
In a comprehensive review of group supervision in 10 pilot sites, Fowler and Dooher (2010) reported that there is “no best way” of conducting clinical supervision and it will most likely fit the needs of individuals and situations. Box 1 lists some of the findings of their review.

Group supervision is often most beneficial when bringing lone workers together for a collective activity. Group dynamics are likely to be at play and must be understood by the participants when using groups for clinical supervision; however, it is not helpful to focus on the processes of group dynamics at the expense of sharing clinical experiences.

Web-based supervision
People working in healthcare will have used tools such as MS Teams and Zoom to communicate with each other. There have been experiments with using the web for clinical supervision, particularly for students, who are often dispersed far and wide on placement and may not have the opportunity to discuss their experiences.

During a two-day programme presented in Slovenia, students were encouraged to make contact with each other on a web platform for support and debate. On occasion, they would invite university academic staff to provide an explanation of problematic clinical situations (Butterworth and Cucek Trifkovic, 2014). Evaluation of the experiment revealed that the students found the process helpful and liked the element of self-control it offered. Academic staff found the material from the experience a useful focus for teaching at university. It is likely that web-based clinical supervision will gain greater traction in the future.

Preparing to take on clinical supervision

Undertaking clinical supervision without adequate preparation is unwise. Becoming a supervisor will pose challenges for most. The supervisor’s focus on interpersonal work – as opposed to organisational issues – has been well delineated in the development of some form of an alliance model of consultative supervision (Inskipp and Proctor, 1993). Indeed, this is a cornerstone for the supervision relationship.

The supervisor’s preparation requires proper focus, but so does the preparedness of the supervisee. It is likely that the most important time to prepare to be a supervisee is as a student, and this learning can be carried through into professional life after qualification. It is perhaps more challenging for experienced professionals to be supervisees, but the experiences learnt through reflective practice will stand them in good stead for engaging in clinical supervision sessions.

A contract of engagement – dealing with session regularity, focus, no-shows and cancellations, and remedial action – is often agreed between the two parties beforehand. Due to critical staff shortages it is fast becoming an ‘employees’ market’ and is likely to stay so for some time, as there are no quick solutions to filling staff shortages. As such, it is appropriate to ask that time is offered for clinical supervision as part of employment practice. If employers refuse, ask them why.

Conclusion

Clinical supervision for nurses and midwives is increasingly becoming more widely used. This is mainly for two reasons: there is a search for support during what has been a challenging time for the profession and a recognition that a supportive, reflective and educational process (such as clinical supervision) has a decent evaluation literature, and we have people that have experienced it and continue to use it. Most importantly, we now have a helpful policy push from government.

There is no one way of undertaking clinical supervision, but nurses and midwives must find a system that best suits them and their organisation. Fortunately, there is a lot of experiential and evaluative literature to help.