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Clinical Supervision


Submitted By louise123
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Clinical supervision continues to be a term evident in everyday language in nursing and definitions of the term are variable. Definitions suggest it has a broad purpose in nursing and can appear to have a lack of accord and focus.

Jones (1999) suggests that clinical supervision offers nurses guidance, support and education and is concerned with quality, safety and protection of clients which reflects the Department of Health ‘Vision for the Future’ (1993) interpretation of clinical supervision as a:
‘formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex situations. It is central to the process of learning and to the scope of the expansion of practice and should be seen as a means of encouraging self assessment and analytical and reflective skills.’

The following assignment aims to demonstrate a critical appraisal of the concept of clinical supervision, critique the process and the outcomes of clinical supervision and review contemporary research that directly informs understanding and application of clinical supervision to practice. It will also reflect on personal knowledge, skills and attributes required for effective clinical supervision and evaluate the impact that clinical supervision has on health and social care practice with the emphasis on my professional discipline of nursing/ mental health nursing.

During this paper I will be reflecting back on my experience of conducting clinical supervision and will refer to myself as ‘the supervisor’ and to maintain confidentiality will refer to the colleague undertaking supervision as ‘the supervisee’. The supervisee is employed within the same NHS Trust and clinical area as the supervisor although has a different professional qualification.

The supervisor currently works as a case manager for the XXXX Programme within an NHS Trust and has a professional background grounded in General and Mental Health Nursing. XXX is a joint initiative between the Department of Work and Pensions and the NHS and aims to deliver a programme of interventions to aid those people who are out of work due to their health condition to gain a sustainable return to work, training or increased activity. The team consists of professionals from a multidisciplinary background delivering the same programme and drawing on each others specialities as required and clinical supervision is encouraged to take place on a monthly basis.

Case managers have access to a supervisor of their choice; due to the distinctiveness of XXX this is usually another case manager with more experience. However as the team is geographically spread over a number of areas the process of choosing a supervisor can be limited and as there is a shortage of case managers who have received training in clinical supervision sessions vary according to the individual conducting the supervision. Clinical supervision can also include managerial issues depending on the supervisor and due to the lack of structure can progress to being more of a chat rather than a reflective practice exercise.

The supervisor has facilitated clinical supervision sessions with colleagues in the past but they have not always utilised clinical supervision or reflective models of practice, therefore the supervisor hopes to implement a more reflective approach to clinical supervision in their own practice and clinical area so as to promote and ensure high standards of practice are maintained and to identify areas for improvement and training.

The NHS trust that is responsible for the delivery of XXX is committed to ensuring all clinical staff has access to clinical supervision. It has provided a clinical supervision policy that provides a detailed overview of what both supervisor and supervisee can expect from clinical supervision and provides a sample clinical/professional supervision contract (Appendix 1), supervision record (Appendix 2) and supervision monitoring record (Appendix3) available to use when conducting and recording of clinical supervision.

Clinical supervision forms part of the clinical governance agenda and supports Care Quality Commission requirements. It is a requisite as part of Care Quality Commission registration that suitable arrangements are in place to ensure staff receive:
‘appropriate training, professional development, supervision and appraisal’ (Care Quality Commission 2010).

XXXX Trust (2010) Clinical and Professional Supervision Policy summarises supervision as ‘essential in achieving and sustaining high quality practice’ and goes on to set out its aim for clinical and professional supervision as supporting the individual practitioners’ development through in-depth reflection on their practice.

Clinical supervision is recommended by registered bodies of Allied Health
Care Professionals and Nursing and was introduced as a way of using reflective practice and shared experience as part of the standards of Continuing Professional Development (Royal College of Nursing 2002). The Nursing and Midwifery Council (2008) formerly the UKCC (1996) supports the process of clinical supervision as a practice focussed professional relationship and recognises the importance of reflective practice in insuring better and improved nursing practice. However despite the emphasis of clinical supervision from professional and statutory bodies Faugier and Butterworth (1994) suggest there is a diverse understanding of the term among the nursing profession and in the supervisors experiences this can lead to some confusion as to how clinical supervision sessions are conducted.

Johns (1995) suggests that reflection is a developmental process where an individual critically explores everyday features of their practice and engages in self- evaluation and appraisal of the experience. Kohner (1994) identifies patient- centred reflective practice as the main purpose of clinical supervision.
However there is a danger that if supervision does not involve a balanced critical assessment that personal reflection can centre on the negatives of an experience.

There are a number of frameworks and models that can facilitate the reflective process. Gibbs Framework for Reflection (1998) is fairly straight forward and encourages a clear description of the situation, examination of feelings, evaluation of the experience, analysis of the sense of the occurrence, what else could have been done and what to do if the situation re-occurs.

Kolb’s Experiential Learning Theory Model (1984) offers both a way to understand individuals learning style as well as a four stage cycle of learning that takes an experience, facilitates reflecting on this event, forms concepts and generalisations for action and tests out these ideas to enable new experiences where as Driscoll’s (2000) model is formatted around three simple questions- what?, so what? and now what? These questions are trigger questions that add to the reflective process.

Johns’ Model for Structured Reflection (1994;1995) can be utilised as a guide for addressing a significant incident or broad reflection of an experience and encourages the use of a reflective diary. Johns’ model adopts some earlier work by Carper (1978) using Carper’s four patterns of knowing and adding a fifth pattern ‘reflexivity’. It is based on five cue questions that enables you to break down the event and reflect on the process and outcomes.

Learning through reflection is more valuable if there is an understanding of reflective models and frameworks. The use of models of reflection were discussed prior to the clinical supervision session by the supervisor and the supervisee and the supervisee concluded that Johns’ model (Appendix 4) was relatively easy to use as it provided clear cues for the supervisee and would fulfil the reflective process. The use of a reflective diary was also encouraged to document experiences to allow for greater reflection of practice rather than reflecting on a lone experience.

Supervision can be provided in a number of ways be it on a one to one basis otherwise referred to as individual supervision where a supervisor is providing supervision to one supervisee and is probably the most common format in nursing (Duarri and Kendrick 1999), peer supervision or group supervision and the frameworks used to structure supervision sessions can also vary.

There is no definitive model of clinical supervision but there are a number of well documented frameworks and models to choose from as a supervisor that can support the successful delivery of clinical supervision, however despite an increase in the number of clinical supervision models documented in nursing literature Rogers (1999) suggests there is evidence to suggest their uptake in specific nursing context is limited.

Driscoll (2000) has described a model for clinical supervision based on Heron’s (1989) six category intervention analysis framework; divided into the ‘authoritative interventions’ these enable the practitioner/ supervisor to maintain an element of control over the relationship and are broken up into prescriptive, informative and confronting categories and the ‘facilitative interventions’ that allow the locus of control to remain with the client/ supervisee and are divided into cathartic, catalytic and supportive categories. It is a conceptual model for understanding interpersonal relationship and understanding possible therapeutic interactions between two people.

A more popular model of supervision is Proctor’s (1986) three facet interactive model, it is the most frequently cited supervision model and has been advocated for a range of nursing contexts including mental health nursing (Cottrell 2001). This interactive model of clinical supervision offers a starting point for anyone thinking of commencing clinical supervision.

Proctor (1986) refers to the normative, formative and restorative aspects of supervision. The normative (awareness and adherence to standards) function of the model refers to what the supervisors responsibility is for ensuring that the supervisee’s work is professional, ethical and within organisational and professional codes of practice, addressing the quality of the supervisee’s practice compared to the standard and can be perceived as focussing on managerial issues. The formative (skills and educational development) phase is where the supervisor acts to provide feedback and facilitate the development of theoretical and practical knowledge so that the supervisee becomes more competent as a practitioner. The restorative (supportive) facet is when the supervisor listens, supports and addresses the supervisee about personal issues and insecurities to maintain stability and boundaries.
However Fowler (1996) argued that there is not one model of supervision that suits the needs of all nursing contexts and Sloan and Watson (2002) recommend that those engaging in the clinical supervision process should decide on the choice of framework.

The supervisor’s organisation does not advocate any particular model for clinical supervision therefore Proctor’s (1987) model was chosen by the supervisor as a framework to facilitate the supervision session as it was the model the supervisor was most comfortable and familiar with and this would allow the supervisor to feel more at ease carrying out the supervision session without being distracted by the need to use an unfamiliar tool which may have inhibited the development of the relationship between supervisor and supervisee and the effective use of interpersonal skills required for successful supervision.

It has been suggested that the relationship between supervisor and supervisee is the single most important contribution to effective clinical supervision (Kilminster and Jolly 2000) and it is argued that the shared understanding of the purpose of supervision sets a firm basis for the supervisory relationship (Sloan 2005).

Within the team this relationship would ordinarily commence with the choosing of a supervisor and the introduction of supervision to the supervisee if they were unfamiliar with the process or to establish the organisation and supervisee’s requirements of supervision. As fore mentioned both supervisor and supervisee are employed in the same team, the supervisor has previously supervised other members of the team but this was the beginning of this supervisory relationship and the direction of the clinical supervision session was new to both.

Fish and Twinn (1997) highlight the importance of clinical supervisors’ preparation to implement supervision as an important consideration in successful delivery of clinical supervision.

The supervisor approached their colleague and discussed with them the context of them beginning this relationship in respect of the supervisors training. The prospective supervisee discussed concerns and queries regarding taking part in the supervision session at this point before agreeing to the sessions. This new supervision relationship was also opportunistic in respect that the supervisees’ current supervisor had recently left the team and so the supervisee was requesting a new supervisor. By addressing the concerns and queries of the supervisee prior to the session barriers and anxieties over supervision were reduced.

Bond and Holland (1998) suggest that anxiety is a frequent and natural experience for both supervisee and supervisor, the aforementioned NHS Trust Clinical Supervision policy lays out the role of the supervisor, supervisee and what the aim and context of clinical supervision, information that can be useful in providing guidance for both supervisor and supervisee that may help in alleviating some anxiety around partaking in supervision.

The supervisor and supervisee agreed to look at the policy together prior to commencing their first supervision session together to establish the organisations requirements. Howard (1997) illustrates how a clinical supervision checklist can be useful in the early stages of clinical supervision relationship as it provides the opportunity for both supervisor and supervisee to get to know each others professional experiences and establish the supervisee’s requirements from supervision however a formal checklist was not used both supervisor and supervisee had worked with each other for some years and were familiar with each others professional experiences.

The supervisor meets the requirements of the organisation; The NHS Trust concerned sets out the requirements of a supervisor as someone who has a minimum of two years post registration experience, however whilst it maybe considered reasonable to expect a supervisor to have experience Devine and Baxter (1995) and Kohner (1994) emphasise the personal qualities of the supervisor such as compassion, honesty and approachability rather that their experience or qualification. Power (1999) pays some attention to the first supervision session and proposes that this is when, what supervisee and supervisor need to know about each other is established, hence supporting the use of a checklist and supervision contract.

Sloan (1998) recognised that the supervisor’s characteristics whilst regarded as one of the most important areas of the relationship between supervisee and supervisor leading to effective clinical supervision where largely neglected in nursing. The supervisor recognised the importance of these interpersonal skills in developing an effective relationship with the supervisee, these skills were already present in the relationship between supervisor and supervisee due to their working relationship, however the supervisor was increasingly aware of the need to practice these skills in the supervision context in order for the supervisee to feel confident in sharing their experiences.

Catmur (1995) suggests the supervisor should have specialist skills, supportive skills and communication skills whilst other characteristics from a supervisor’s perspective include promoting autonomy, being knowledgable and competent, provide feedback on performance and provide specific ideas about interventions (Pesut and Williams 1990). The supervisor was confident that they were able to mirror these skills in supervision and felt confident in the supervision process, on reflection this was due to the past experiences of the supervisor in this role and in providing clinical supervision in the past. Alternatively Fowler (1995) and Sloan (1999) on investigating characteristics from a supervisee’s perspective found similarities such as formation of a supportive relationship, having good listening skills, possessing relevant knowledge and clinical skills as well as a commitment to clinical supervision. The supervisor and supervisee discussed at the pre supervision meeting what they felt were important skills for the supervisor to possess and they were reflective of these findings as well as the confidence in confidentiality and a non- judgemental approach from the supervisor.

Recording of the supervision session was also discussed and in keeping to the organisations requirements it was concluded that when clinical supervision sessions had taken place it would be documented and the clinical supervision monitoring record (Appendix 3) updated to provide evidence of supervision. The contents of the sessions would be recorded for personal use on the clinical supervision record (Appendix 2) and kept by the supervisee as well as other notes taken in the session being verified by the supervisee and copies kept by the supervisee with the supervisor taking and keeping notes if they were thought to be essential for future sessions. The use of the reflective diary and notes pertaining to this were to be kept by the supervisee.

However Johns (1996) advocates that the supervisor always takes notes and these are then used at the next supervision session, enabling the supervisor to highlight key issues. This could be argued that this may take the focus away from the supervisees’ requirements at the next session and focus on the supervisors perspective of what is needed.

Powers (1999) supports that the recording of information such as date, start and finish time, names of those attending, brief notes of the content of the supervision and the next supervision date be recorded as these aspects are pertinent to the organisation of supervision.

Alternatively Clark et al (1998) argue in favour of the minimum amount of recording in supervision sessions and suggests that only the contract set out at the start of supervision be the only record kept; a view supported by Bond and Holland (1998) where concerns are recognised that if supervision records identify a particular client then the client has the legal access to these records and if supervision takes place during working time then the employer maybe able to access them and use them in disciplinary proceedings. However with the introduction of the Care Quality Commission (2010) t is a requisite as part of Care Quality Commission registration that evidence that supervision is taking place is apparent.

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