mplementing

clinical
supervision
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.

Stage one
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.

Stage two
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?

Stage three
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:

- Support;

- A definition of clinical supervision;

- Models and frameworks of supervision;

- Setting up a supervision agreement;

- Challenging poor performance;

- Problem-solving.
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.

Stage four
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.

Success factors
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.