Implementing clinical supervision (part 1): a review of ...

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Clinical supervision

Implementing clinical supervision (part 1): a review of the literature James Turner and Alison Hill present part one of a three-part paper on clinical supervision James B Turner Principal lecturer, Sheffield Hallam University, Sheffield. Correspondence: [email protected] Alison L Hill Lead nurse community mental health, NHS Barnsley Care Services Direct. Correspondence: [email protected] Abstract This article represents part one of a three-part series incorporating a review of the literature, a study relating to implementing clinical supervision into a ward-based environment and current practice in regards to the support of clinical supervisors in a community mental health setting. Proctor’s (1987) Tripartite model is the supervision model of choice and provides commonality between the studies. Clinical supervision remains a development target for many clinical areas, alhough for some the integration of supervision with practice has been fostered and supported for many years. The literature shows that implementation varies greatly between regions and disciplines. It seems therefore, that in the wider workforce, clinical supervision still requires commitment and energy to mange the time and continuity for successful practice. This paper reviews the literature on clinical supervision in nursing and allied helping professions in relation to the studies that will follow. Key words Clinical supervision, Proctor’s model, implementation Reference Turner J and Hill A. (2011) Implementing clinical supervision (part 1): a review of the literature. Mental Health Nursing 31(3): 8-12.

Statement of the problem The health service seems to always be changing, restructuring and organising itself, yet within this change clinical interventions and therapeutic contact remain a constant activity. This therapeutic encounter is the where the importance of clinical supervision lies and also the context of a number of health initiatives. The Darzi Report (Department of Health, 2008) indicated the desire for ‘high quality care for all’ and in Modernising Nursing Careers (Department of Health, 2006) a framework for career progression was set out. Clinical supervision can be a bridge and a support in managing these changing times, focusing on the activity of the nurse and the standards expected of that activity. The background for our first study was that clinical supervision was often practised in an unplanned and poorly supported manner, being ‘fitted in’ to periods of reduced activity. Momentum for this study began with a need to structure clinical supervision, manage skill mix changes, and as a response from a nursing team away day for structured clinical supervision. At the away day a supervision tree was established and gained support. In the second study, in a setting where formal supervision is more embedded into practice, we explore the support needs of clinical supervisors. Incorporating evidencebased practice into their clinical supervision in line with the vision of the chief nursing officer’s review of mental health nursing (2006).

Aims of study 1 1. To evaluate the implementation of Proctor’s (1987) model of clinical supervision. 2. To test a number of hypotheses based on this: a. That clinical supervision is valued as a process in dealing with Proctor’s three areas of Formative, Normative and Restorative. b. That Restorative aspects may be the

primary need of acute mental health nurses from clinical supervision. c. That using documentation of the clinical supervision sessions facilitates continuity of clinical supervision.

Aims of study 2 1. To evaluate the impact of support and update resources on clinical supervisor’s practice, particularly with regards to the incorporation of evidence-based practice (support in fulfilling the formative and normative functions of Proctor’s model). 2. To determine if there would be an impact on supervision activity if clinical supervisors were more supported and offered resources.

Background considerations The importance to NHS organisations of nurses engaging in clinical supervision has risen since the introduction of ‘clinical governance’ (Department of Health, 1997; Department of Health, 2000), where clinical supervision can be seen as a tangible process of professional regulation – and can be considered a central plank of the clinical governance framework (McKeown and Thompson, 2001; White and Winstanley, 2010). Presently there is an increased focus on evidence-based practice through the monitoring of the implementation of NIHCE guidance by the Care Quality Commission (Department of Health, 2010). Proposed changes that give a greater focus on outcomes, both with regards to improving patient experience and recovery and the introduction of payment by results; i.e. healthcare providers’ performance will be measured to ‘reflect outcomes, not just activity’ (Department of Health, 2011), which gives more strength to clinical supervision in its role as a vehicle for facilitating changes in clinical practice and incorporating

Clinical supervision evidence-based practice. The impact for a clinician is primarily for improving clinical practice and delivering the required outcomes, although evaluation of resource usage and value for money should also be considered. Clinical supervision is one of many processes that assist in both evaluation and clinical improvement. The studies are also stimulated by recommendations from over 20 years of key policy documents. For example Vision for the Future (Department of Health 1993) states: ‘New ways must be found to support nurses, in maintaining, developing, high standards of clinical practice ... by the development of peer review, clinical supervision (our italics) and innovative research based practice.’ It is suggested that the studies undertaken do exactly this. Further, this observation has been more recently supported by Butterworth et al (2008: 270) in noting: ‘Employees who are supported and are allowed time to reflect and develop will make a significant contribution to patient well-being and safety…’ and describing the related role and responsibility employers must take to facilitate this. In terms of the implementation of clinical supervision, it has steadily gained ground over the years. However, the notion of clinical supervision is believed to have been part of mental health nursing for some time (Bond and Holland, 2010), with studies showing uptake of 60% and above (Kelly et al, 2001; Magnusson, 2002; Edwards et al, 2005; Hyrkas, 2005) should be treated cautiously as being representative of uptake in mental health throughout the NHS. However, it can be assumed from studies in the uptake in other nursing disciplines (Cheater and Hale, 2001; Teasdale et al, 2001) that it probably is more prevalent in mental health practice.

Literature review An initial review of the literature revealed an abundance of literature on clinical supervision – both generally and in mental health settings. However, focused searches on different issues within this field yielded a variance in amount of literature dependent on the issue chosen. For example, there is a great deal of literature written about evaluating the efficacy of clinical supervision, where as there is much less on the training of supervisors. Literature was examined from a variety of

sources. Key words used to locate literature on clinical supervision included clinical supervise and/with; models, frameworks, implementation, reflective practice, relationships, burnout, theory-practice gap, training, resources, support and evaluation. An unrestricted search was carried out on the databases CINAHL, Medline, PsychINFO, Cochrane and BNI, while a manual trawl of abstracts was used to detect relevant material. Reference lists in key literature such as Faugier and Butterworth’s (1993) position paper on clinical supervision, Bishop’s (1998) book on clinical supervision in practice, Cutcliffe et al’s (2001) Fundamental Themes in Clinical Supervision, Sloan’s (2006) Clinical Supervision in Mental Health Nursing and Butterworth’s (2008) literature review were manually scrutinised for additional data, especially that which could be potentially unlisted or inaccessible. The internet was also used to obtain relevant material to this field of interest. Searches were carried out throughout the life of the project to capture any new data that became available. The organisation of this literature review will follow a sequential pattern of what, why, how, process, functions, problems, models and lessons from other professions regarding clinical supervision.

Presently there is an increased focus on evidence-based practice What is clinical supervision? A criticism of clinical supervision is the range of definitions, what it constitutes and its ‘potent components’ (Sloan and Watson, 2001: 1). Bond and Holland (2010: 13) go so far to say that there are ‘as many written definitions of clinical supervision as there are published books and papers on the subject’. Williamson and Perez (1990) state it is ‘a process by which a nurse of lesser experience is assisted by a clinician of greater experience to develop self-awareness and therapeutic skill’. The Open University (1998: 1) gives a ‘fuller working definition’: ‘Clinical supervision

provides time out and an opportunity, in the context of an ongoing professional relationship with an experienced practitioner, to engage in guided reflection on current practice in ways designed to develop and enhance that practice in the future.’ A third definition from Bond and Holland (2010: 14) provides insight regarding difficulties defining clinical supervision ,which they state is ‘incomplete’ and ‘cannot stand alone without examination of the principles behind it’. Within these definitions reoccurring themes resonate with earlier policy aspirations, such as ‘an interpersonal process where a skilled practitioner helps a less skilled or experienced practitioner to achieve professional abilities appropriate to their role’. At the same time they offer counsel and support’ (Department of Health, 1993: 18). Counsel and support are an often-noted theme (Butterworth and Faugier, 1994; Barton-Wright, 1994), with Butterworth et al (2008: 270) stating: ‘Clinical supervision as a supportive device has attracted more attention than any other.’

Why practise clinical supervision? Rolfe (1994: 193) comments: ‘Peplau… argued that supervision is practised in social work, teaching, counselling and psychotherapy, hence psychiatric nurses do all these things, therefore should practise supervision’. Butterworth et al (2008: 270) acknowledge that studies have supported positive experiences to clinical supervision and caution that effects cannot be attributed solely to clinical supervision, stating: ‘... it is quite proper to suggest that structured opportunities to discuss case-related practice, personal and educational development are vital to nurses, their practice and patient safety.’ Butterworth recommends in Working in Partnership that ‘clinical supervision is established as an integral part of practice up to and including the level of advanced practitioner for mental health nurses’ (Butterworth, 1994: p21). However, information from the literature indicates that the effective implementation of clinical supervision particularly in mental health should not be taken for granted (Thomas, 1995; Carson, 1995; Rice et al, 2007; Bond and Holland, 2010). A report for the Health and Safety Executive

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Clinical supervision (Cox et al, 2002) looking at stress in hospital staff noted that: ‘work-related stress is currently one of the greatest challenges to the health of working people and to the healthiness of their work organisations’ and added there was no evidence to indicate this would not remain a considerable challenge. Stress can lead to decreased motivation, lowering of clinical standards and burnout (high levels of emotional exhaustion, depersonalisation and low levels of personal accomplishment (Edwards et al, 2005)). Care is only as good as the nurse who provides it, and it is therefore suggested that a role of the clinical supervisor is to ‘release nurses from strain, thereby preventing a negative outcome’ (Hallberg and Norberg, 1993). Edwards et al’s (2005) study of community mental health nurses in Wales suggested: ‘if clinical supervision is effective then nurses report a lower level of burnout’. This concurs with an earlier smaller scale study by Hallberg (1994), which noted that ‘stress, tension and burnout’ were seen to be alleviated by clinical supervision. Managing stress through clinical supervision can also support standards of care, as clinical supervision can be a tool for learning and refining the patient assessment, diagnosis and treatment skills of psychiatric nurses (Platt-Koch 1986).

How to do clinical supervision There are now many instruction manuals giving examples of models, details of the micro-skills required and the pitfalls to avoid when carrying out clinical supervision (for example, Hawkins and Shohet, 2000; Driscoll, 2007; Scaife, 2009; and Bond and Holland, 2010). In study one, in the researcher’s workplace group supervision, peer supervision and oneto -one supervision took place, which involved experienced staff, including the line manager as a clinical leader facilitating the process. Some individuals had access to an external supervisor, the researcher included, who received external and peer supervision. Team or group supervision dealt with case presentations, where people could talk about difficulties with clients, or a particular influential client. It was felt when dealing with transference problems, as noted by Bonnivier (1992), recognising ‘counter-transference feelings so as not to get drawn into patients mood’ is essential. Reflective discussion (Hallberg and

Norberg, 1993) also recognised the positive effects of talking about individual patients, the emotions evoked, experiences and the way staff related to that individual in peer supervision sessions. Group supervision and one-to-one supervision appeared to follow the counselling process of ‘identifying, describing relationships and prescribing treatment plans’ (Biggs, 1988) and the models, particularly of group supervision, involved ‘interactive and interdependent structure, where no one person is clinical supervisor’ (Baretta et al, 1993).

The process of clinical supervision This involves who should do it, where, when, frequency and ground rules of the supervisor/supervisee relationship. The system for delivery is integral to the model of supervision. Faugier and Butterworth (1993: 33) describe the many different systems available, from one-to-one sessions, to group supervision to network supervision, all offering a choice of supervisors – nurses, nursing academics and other disciplines within the team.

The problems of supervision begin with training for supervisors The choice of delivery system can affect the experience of clinical supervision (Faugier and Butterworth, 1993), in White et al’s (1998) study the majority of nursing staff chose a one-to-one relationship and this finding was replicated in a large study by Edwards et al (2005). However, White and Winstanley (2010) state in their study that the delivery of clinical supervision per se is ‘commonly’, via ‘small groups’, which reflects a change in the common form of delivery compared to previous studies. In study one, the ‘who’ included the line manager, though Bond and Holland (2010: 21) in contrast to earlier authors (Whybourn, 1994; Farrington, 1995) caution against the use of line managers delivering supervision to sub-ordinates believing this could ‘…lead to restrictive practice rather than reflective and growthful practice.’ However, many

people’s experience of clinical supervision in the earlier years of implementation were that the clinical ‘expert’ was the line manager who was, it was felt, if clinically involved, well placed to offer supervision. The line manager as supervisor, argued Barton-Wright (1994: 28), has many positives: ‘Enabling charge nurses to maintain a clinical focus, focuses the role in clinical practice and prevents it becoming purely managerial, develops clinical power and autonomy, provides ability to monitor quality of care, promotes primary nurses’ clinical knowledge, encourages knowledge of legal responsibilities, standards maintained’. In study two, line managers were less likely to be offering clinical supervision to their subordinates, as their supervisor training drew attention to the problems, especially around the differentiation between clinical and management supervision where the same person was delivering both.

The functions of clinical supervision Proctor’s model (1987) provides a good framework and is one of the most cited models in the UK nursing literature (Faugier and Butterworth, 1993; Nicklin, 1995; Cutcliffe and Proctor, 1998; Bowles and Young, 1999; Sloan, 2006; Bond and Holland, 2010). First, it suggests that clinical supervision is formative, the function is an educational process of developing skills. Second, it is restorative, offering support. Third, there is a normative function involving quality control aspects of clinical practice (Proctor, 1987; NHS Executive, 1994; Butterworth, 1994; Kohner, 1994). Rich (1993) notes further that clinical supervision has four functions: ‘facilitating a supportive learning and work environment, fostering staff development, providing a means for the professional socialisation of staff and ensuring delivery of effective client services’. These also can fit into the formative, restorative and normative model and called ‘educative, supportive and managerial’. A second recurring functional theme (Rolfe, 1990; Byrne, 1994; Barton-Wright, 1994), in that clinical supervision helps develop skills, deal with stresses precipitating burnout, has quality issues, provides feedback and provides for the management of the clinical environment through use of these functions.

Clinical supervision Proctor’s model has been criticised by Sloan and Watson (2001) for lack of detail in its application. However, a positive from this is that this allows space for the necessary creativity that developing clinical practice requires, this will be discussed further under ‘models’.

The problems of clinical supervision The problems of clinical supervision begin with adequate training for supervisors, as there is no standardised programme or agreement as to what training is required to deliver competent and confident supervisors (Kohner, 1994; Cutcliffe and Proctor, 1998; Epling and Cassidy, 2001; Butterworth et al, 2008). Once this hurdle is dealt with, problems surround who should do it, resources, and support, and time considerations (Butterworth, 1994; Nicklin, 1995; Rice et al, 2007; Bond and Holland, 2010). The time issue is sometimes dealt with through the use of group supervision strategies though the bulk of social work, education, nursing and psychological research into clinical supervision focuses on individual supervision as being most positive. One of biggest problems clinical supervision faces is the lack of empirical evidence to support many of the positive claims made for it. This creates difficulties when considering the cost of clinical supervision and the competing priorities for funding within the NHS, as Neil Brocklehurst reflects (as one of the members of ‘The West Midlands Clinical Supervision Learning Set’ in 1998: 17) that they had to undertake a ‘frenetic search for evidence of its [clinical supervision’s] added value to the NHS’. The reason for this being: ‘the urgent need to justify money being spent on clinical supervision by NHS trusts and health authorities.’ Studies that have been conducted into identifying that knowledge and skills acquisition takes place in clinical supervision have shown mixed results (Sloan, 2006), with many relying on self-reporting and the numbers studied being small. A recent study looking at the effect of supervision on outcomes for mental health nurses and the service users they worked with during psychosocial intervention education showed tentative positive findings, both in the acquisition of PSI knowledge and

skills for the nurses and improved well-being for the service users, though again the numbers were small (Bradshaw et al, 2007). The recent Australian White and Winstanley large-scale study (2010: 162) set out to show a causal relationship between clinical supervision and improved patient outcomes in mental health, but again this relationship remained ‘elusive’, providing ‘no statistically significant differences in patient satisfaction and quality of care’. However, it did provide some insights into the pivotal role of middle managers in effective implementation – the benefits that clinical supervisor training, being part of the project and delivering clinical supervision in their workplace brought to the clinical supervisors and raised a challenge about ensuring quality clinical supervision was being delivered. A further barrier is that clinical supervision can be seen by practitioners as being somewhat negative, being ‘associated with discipline and correction’ (Rolfe, 1990: 193). Bond and Holland (2010: 14) consider the use of the term ‘supervision’ may be met with suspicion, as it implies ‘keeping an eye on someone, checking that work is being done appropriately and effectively’.

Models of clinical supervision Development of the many models of clinical supervision has perhaps been influenced both by the lack of consensus in definition and also the complexity of the task, as models act as devices to assist an improved understanding of phenomena (Milne, 2009). As mentioned earlier, Proctor’s ‘Three Function Interactive Model’ (1987) is one of the most commonly cited models and the model implemented in both studies. It does seem that Proctor’s model can be used alongside differing definitions of clinical supervision and remain credible, as in Bowles and Young’s (1999) study, which supported the relevance of Proctor’s model as the most preferred theoretical framework. Proctor (2001: 27) herself guards against the ‘one size fits all’ approach with regards to clinical supervision, urging healthcare practitioners to ‘develop supervision training, models and skills which are immediately useful and practicable in their own context, within professionally agreed tasks and responsibilities.’ Sloan (2006) concurs with this, stating

that attempts to impose one model over another may be imprudent and problematic for practitioners. Many of the models in use in nursing have been taken from the fields of counselling and psychotherapy, and may be grouped into three types, developmental models, therapy models and specific (task-focused) models. Much of the related research attracts criticism, as Milne (2009: 46) states: ‘it is rare for researchers to demonstrate objectively that supervisors are adhering to the given model.’ In study one the close relationship of the researcher to the team assisted with feedback around adherence to the model. In study two adherence to Proctor’s model was only sought in its broadest sense.

The lessons from other professions Supervision should be free to ‘explore idealised therapeutic relationships... aiming to release creative potential’ (Sanville, 1989). It is felt that creativity and ‘fun’ can be restorative and therefore has relevance in both individual and group work. Frankel and Piercy (1990), in their supervision in family therapy study, found a significant relationship between effective support during supervision and the subsequent use of support by their supervisees with clients. The more support that was offered in supervision the more likely the supervisees were to support their clients. Another lesson is the emphasis placed on the therapeutic relationship, being conscious of transference and counter-transference issues. The focus on counselling and humanistic working certainly provides for a therapeutic relationship, which may have transference issues.

Conclusion As this literature review illustrates, clinical supervision is a complex process and therefore no one should be surprised that implementation across the workforce remains patchy and remains a challenge. The studies that follow in this series offer insights into some of the difficulties and possible solutions when implementing this initiative, both for practitioners at the beginning of the journey who are considering implementing it for the first time (part 2) and (part 3) for those who have embraced clinical supervision within their practice. MHN

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