CLINICAL

SUPERVISION
Murtada Chaaban
Head nurse Hemodialysis units
KFSH&RC Riyadh
chaabankfshrc.edu.sa

Objectives

Understand the Clinical Supervision (CS).

Identify the benefit of CS.
comprehend the aim of CS.
Relate the CS to the concept of learning.
Recognize different models of CS .
Differentiate between CS and management.
Identify the characteristic of Clinical
supervisor
Recognize the component of CS contract.

Introduction
CS is highlighted item on nursing agenda
since (1980)
CS has been described as a formal
arrangement that bring nurses to discuss
their practice regularly with another
experienced professional.
CS is an interpersonal process whereby a
skilled practitioner helps a less skilled or
experienced practitioner to achieve
professional abilities appropriate to their
role, (Barber &Norman, 1987)

Definition
CS is a formal process of professional support
and learning which enables practitioners to
develop knowledge and competence, assume
responsibility for their own practice and
enhance consumer protection and the safety
of careits central to the process of
learning encourage self assessment,
analytical and reflective skills. (NHS, 1993 ).
CS brings practitioners and skilled supervisor
together to reflect on practice. Supervision
aims to identify solution to problems, improve
practice and increase understanding of
professional issues. (UKCC position statement,1996).

CS aims
CS is a formal support system that aim :
Steered reflection in practice.
Provide support to avoid mistake
recurrence
Create an environment where good
practice can challenged, developed,
and improved,
Enhance positive and healthy working
environment.

Components of CS
CS require three main components:
Infrastructure; the administrative
foundation that allows work based learning
Relevant experience which provide
opportunity to enhance individual skills
through exposure to learning opportunity.
Learning culture; the value that the
organization and people within place
engaging learning for growth and
development.

Function of CS
There are three main function of CS (Proctor 1986).
Formative; is the educative process of
developing the skills, understanding and
abilities of practitioners.
Restorative; is about supporting the
practitioner to adopt their copping skills,
in relation to the varying levels of stress
within the clinical setting.
Normative; is where the practitioner looks
at the quality of his work and how this fits
within the standards.

Potential benefits of CS

Personnel development/growth .
Identify learning needs.
Improve working relationship.
Enhance reflection on practice.
Opportunity to receive positive
feedback.
Provide link between research and
practice (Identify research subject).
Provide emotional support for the
practitioner (far from the managements).

Potential benefits of CS
Individual recognition of a sense of
personnel worth and the sense of
being valued.
More effective use of skills,
knowledge and expertise.
Develops innovative practice
Better quality of care for the clients.
Acknowledgment of stress and
difficult workloads.

Potential benefits of CS
Improves patient/ client satisfaction.
Contributes to risk management and
decrease adverse occurrence incidents
Increase staff satisfactions and by
consequence staff retention.
Maintain and safeguards standards.
Improve qualities of care.
Protect the patients receiving care
from the nurses and protect nurses
(Barker 1992).

Factors affecting CS
The implementation of CS is
affected by two main factors
that influence its presence for
nursing/ health professions:
1) External factors.
2) Internal factors.

?Why CS IS Needed
External influences summarized:

Presence of patients Charter leading to

increased expectation from the public
(DOH 1992).
Increased awareness of a growing need
to manage risk in modern health service
(Tingle, 1995).

Dynamic changes within current health

system (darley,1995).
Recent innovation in the medical
management and treatment of patients
(Kohner, 1994)

?Why CS IS Needed
Internal professional influences can
be summarized:
Professional regulatory body and it
role that:

Is entrusted to protect the interest of the

public. (code of conduct)
Stat the professional requirements for
education and practice. (license)

Development of professional
accountability. (code of conduct)
Introduction of the scope of
professional practice.

?Why CS IS Needed
Emphasis on the continuous
professional development (LLL).
Accelerating organizational change
(Palsson et al, 1994)

Complex health needs (DOH, 1992).

Demand for research and evidence
base practice. (Bats tone & Edward, 1997)
Movement of nursing from task
oriented towards more individualized
approach (Rogerson et al, 1993)

?Why CS IS Needed
Increase development of independent
practitioner roles (Dolan et al, 1997)
Integration of nursing education into
institutions of higher education (Fish and
Twin, 1997).

Development of multi-professional
partnerships (including patients).
Increase usage of clinical audit & QA
and customer feed back.
Response to increase workload

Is Professional Support
Necessary for Nursing?
The nursing profession has
continually acknowledge the value
of developing professional support
system (Casement, 1992; Smith 1992)
The need for organized support
system is well expressed in the
literatures, ( Firth &McIntee1984).
Despite that recognition, Nursing
profession has tended to neglect
the idea of professional support
and view occupational pressure as
for the individual to deal with.
(Hingley & Harris 1986; Bowman 1995)

What Elements Constitute

a Support System (SS)?
In each organization there are always
some sort of SS, that can be
classified in two types:

Formal SS:

mentorship, Preceptorship,
Performance appraisal, Education program,
Research projects, Clinical supervision, .

Informal SS: Team nursing, Staff

meeting, Morning report, Peer relationships,

Journals, books, Internet facilities, ward
project, Symposium etc

Common Roles of the SS

Offer individual and professional
development.
Encourage and motivate staff.
Enable identification of the
learning needs.
Facilitate learning.
Offer emotional support.

Uniqueness of CS
Authors see Preceptorship,
Mentorship and Clinical Supervision
as a continuum rather than
substitute for each other (Holland &Band 1997).

The specific characteristics of

Clinical Supervision are:
CS is formulated mainly for the
clinical senior nurses.
Facilitate the learning in clinical
environment.

Uniqueness of CS
Enhancement of standards of care
through ensuring that practice is
safe and evidence based.
Enabling role development and
innovation.
Offering clinical leadership.
Promoting reflective practice and
the development of critical thinking
skills.

Uniqueness of CS
The process of CS should be
developed by managers and
practitioners according to the local
circumstances.
Ground roles should be agreed, at the
beginning; written contract include
the purpose of the CS session,
confidentiality disclosure, consent, if
CS included in the employment
contract document can be requested
by the mangers, otherwise not
allowed!

Uniqueness of CS
Every employee should have access
to CS. (once/year).
Each supervisor should supervise a
realistic number of practitioners.
Preparation of supervisors is crucial
for the CS success.
Evaluation of CS is needed to assess
its influence on the practice.

Uniqueness of CS
Clinical supervision is not:
Managerial control system.
The exercise of overt managerial
responsibility.
Formal performance assessment.
Disciplinary action.
Personal counseling.
Hierarchical in nature.

Approaches to CS
CS can be carried out in many ways
and with different people. (Houston 1990;
Barton-Wright 1994; Faugier &Butterworth).

Self Supervision where the individual

is able to reflect upon his/her work.
Team supervision; among a group of
colleagues who work together (Primary
nurse team).

Network supervision; among people

who do not work together (community nurses)

Approaches to CS
Group Supervision; between a group
of colleagues who have a common
link ( Preceptors).
One-to-one Sessions which I believe
is the most effective approache:
Expert supervisor from the same
discipline ( senior/Junior).
Expert supervisor from different
discipline ( IV nurse).
Peer supervision; colleague of a similar
expertise and grade, (may be lower).

Clinical Supervisor
Clinical supervisor play essential
role in the success of CS. The
preparation of Clinical supervisors is
crucial, relevant practice,
experience is important as well as
the development of the necessary
skills, qualities and characteristics
to achieve the required outcomes.

Clinical Supervisor
Qualities and characteristics of a good
clinical supervisor (Piemme et al 1986;
Fowler 1995; Mahood et al 1998):
Knowledgeable on the supervisor
roles, supervisees role, supervision
models. clinical credible
Skills: teaching (adult learning) assess
knowledge and experience,
communication, interpersonal,
reflection (can be reflective and facilitate
discussion and reflection).

Clinical Supervisor
Objective clinician, open
mindedness, non-judgmental, non
abusive, non-threatening,

Genuine, self-aware, self-confidence

assertive, organized
Approachable, flexible, empathetic.
patience, have sense of humor.
Advisor, coacher, sponsor, counselor
Resource facilitator.
Role model.

Models of CS
There are several models of CS:
Interactive/Functional model based
on: (Proctor 1991)

Normative tasks that help people to

develop standards.
Formative tasks that help people to
develop skills.
Restorative tasks help to validate each
other and develop a climate of safety
(Useful to initiate CS).

Models of CS
Integrative or Process model: the
focus in this model is on the process
of the tripartite relationship during
the supervisory session; (supervisor supervisee
& the patient in addition to work context), tasks and
functions are made explicit. This
model most useful when the primary
work of the nurse is the use of self
reflection on the nurse/client
relationship. (Hawkins and Shohet 1993).

Models of CS
Relationship or Growth and

support model: the focus on the

nature of supervisory relationship
and how the development of the
supervisee affect this relation. Also
it provides guidance to the
supervisee and the supervisor roles
(Generosity, humanity, rewarding; openness, willing
to learn, thoughtful etc) (Faugier 1992)

Factors affecting CS
Knowledge of the concept of CS
Commitment to the philosophy and
process of CS.
Space and time is needed for CS to
take place effectively.
Confidentiality is essential to build
trust relationship.
Previous experience of CS both good
and bad.

Factors affecting CS
Organizational blocks, senior
managers play a crucial role on the
implementation of CS.
Maintaining the boundaries without
influencing the other work relation.
Personal ability to learn and to deal
with criticism. And to provide positive
criticism.
Accountability; clinical supervisor is
not responsible for the action of the
supervisee.

Components of CS Contract
In addition to the biographic data it
is recommended that the CS
contract should include five stage:
Stage I:
What are the expectation of each person
entering in the supervisory relationship?
What are the goals of the CS session?
What benefit do you want from CS?
Which model would be used?

Components of CS Contract
Stage II:
When the sessions will begin, and
how often?
For how long each session will be?
Do we need to keep record? If yes
For what and which method of
record is going to be used?

Components of CS Contract
Stage III:
What will happen if professional
standards are compromised? e.g.
Unacceptable professional conduct,
or unsafe illegal practice,
circumstances where
confidentiality may have to be
disclosed and how this will be
achieved.

Components of CS Contract
Stage IV:
How the sessions will be structured?
What tools will be used? (for daily learning)
How to ensure continuous focusing
on CS within each CS session?
What issues are not appropriate for
CS?

Components of CS Contract
Stage V:
When the contract will be revised?
What circumstances necessitate the
contract to be reviewed? (change of post).

If Clinical supervision included in the

employment contract, employer can
have access to the supervision
documentation without supervisee
consent.

Conclusion
I would like to ask you answer:
Do you think we need to have
Clinical supervisor ?
If No what is the alterative?
If yes, what you are going to do
to implemented?

Thank you
Murtada
Chaaban
Head Nurse KFSHRC Riyadh
chaaban@kfshrc.edu.sa

References

Barber, P. & Norman, L (1987) Skills in supervision. Nursing Times 83; 83(2), 3-4
Barker P (1992). Psychiatric Nursing. In: Butterworth T and Faugier J (Eds).
Clinical Supervision and Mentorship in Nursing p 65-79 Chapman & Hall.
Benner P. (1984) From Novice to Expert. Excellence and power in Clinical
Nursing. California Addison- Wesley. USA.Bodley, D.E. (1992) Clinical
supervision in psychiatric nursing: using the process record. Nursing Education
Today 12(2), 148-155.
Bond R and Holland S (1997). Skills of Clinical Supervision for Nurses.
Buckingham, Open University Press.
Borrill, C.S. et al. (1996) mental health of the workforce of NHS Trusts-Phase 1
final report Institute of work Psychology, University of Sheffield & Department
of Psychology University of Leeds. (art 21mc)
Booth K (1992)Providing support and reducing stress: a review of the literature.
In: Butterworth T and Faugier J (Eds). Clinical Supervision and Mentorship in
Nursing. London, Kogen Page.
Bradshaw, Teaching and assessing in clinical Nursing Practice. London: Prentice
HALL. (1989) (1997).
Butterworth, T. & Woods, D. 2001 Clinical Governance and Clinical Supervision
working together to ensure safe and accountable practice. The School of
Nursing, midwifery and Health Carthy, J. (1994) Bandwagons roll. Nursing
Standards 8(38), 48-49.
Cottrell, S. & Smith, G. (2000). Problematic Dynamic Relevant to the Implementation
of Clinical Supervision in Nursing. http://www.clinical-supervision.com
Cottrell, S (2000) Draft Policy for Clinical Supervision.
Cottrell, S. (2000) The Journal of Psychiatric and mental health Nursing July 2000

References

Smith, G., (2000). Friendship within clinical supervision: A model for NHS?
Presentation for launch of National Nursing Strategy for wales: 'Realising
the potential' Sept. 2000. www.clinical-supervision.com./supervion
Stokoe, B. & McClarey, M. (1995). Safety Measure. Nursing Times; 91(26),
30-31.
The New Shorter Oxford English Dictionary, (1993). 4th ed. New
York:Oxford University Press. Thumb Index edition.
Titchen, A. and Binnit, A. (1995) the art of clinical supervision. Journal of
Clinical Nursing 4:327-334.
Tschudin V. (1992) Making Ethical Decision' in Ethics in Nursing: The
caring Relationship (2nd ed) London: Butterworth Heinemann p82-92
Vance C and Olson R (1991). Mentorship. In: Fitzpatrick J J, TauntonRL and
Jacox AK (Eds). Annual Review of Nursing Research.New York, Springer.
Watkins, M.J (2000). Competency for nursing practice. Journal of Clinical
Nursing 2000; 9: 338-346.
Weinberg, A. & Creed, F. (2000). Stress and psychiatric disorder in
Healthcare Professionals and Hospital Staff. The Lancet, 355 Feb. 12th
2000. (art 21mc)
Webb, A. & Wheeler, S (1998) how honest do counselors dare to be in the
supervisory relationship: an exploratory study. British Journal of Guidance
& Counseling, 26:4.
Wright, B. (1993) Clinical Supervision. Accident and Emergency Nursing
1(4), 181-182.
http://www.clinical-supervision.com./supervion%20policy.htm. 02/02/1427
http://www.clinical-supervision.com