What is Clinical Supervision?
Over the last few decades, Clinical Supervision has become part of the requirements of nursing and wider professions such as therapists and is recommended in public policy statements alongside regulatory inspections.
Credible research evidence has accumulated to demonstrate that supervision has a positive effect on the well-being and workplace burnout (studies such as Tomlinson: BMC Med Educ. 2015; 15: 103 – Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis).
However, much less data is held on the quality of the supervision and therefore evidence of long term impact is minimal.
Logic would predict that it is unlikely that a one size fits all approach will work. This recognises that we are all individual in our learning style and therefore research needs to explore how practitioners best access supervision, how they best learn and how they can experiment and embed new knowledge, skills and behaviours.
The contemporary priority is to document the volume of supervision activity to ensure we are compliant with regulators, to count how many and how often staff access supervision but they do not focus on the quality of provision.
The NMC revalidation requirements includes practice-related feedback, written reflective accounts (Gibbs templates provided), reflective discussions (https://www.nmc.org.uk/revalidation/resources/forms-and-templates/)
Tthe GMC has quality improvement embedded with documentation of continuing professional development that has collection of information, reflection and discussion included as part of annual appraisal and revalidation https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice/the-reflective-practitioner—guidance-for-doctors-and-medical-students
Wider professions utilise supervision as part of their standards, https://www.bacp.co.uk/events-and-resources/ethics-and-standards/competences-and-curricula/supervision-curriculum/ and social workers have included supervision as a critical part of their practice – https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/778134/stengths-based-approach-practice-framework-and-handbook.pdf. The HCPC identifies CPD as core to registration. https://www.hcpc-uk.org/cpd/your-cpd/our-standards-for-cpd/
It therefore makes sense, that supervision models are transferrable across the health and social care landscape but we should consider how this incorporates wider non clinical roles, strategic roles alongside registered professionals. Integrated Care Systems create an opportunity for multi-organisational supervision.
As a practitioner who has worked in justice settings, consideration should also be given to whether wider public sector roles would also benefit namely policing in light of their cultural challenges.
How do we measure success of supervision?
We need to evaluate what is the measurable impact of supervision?
Is there a model which creates better outcomes?
How much do these cost?
And which groups would benefit from supervision?
- What are staff retention rates in groups experiencing supervision vs no supervision?
- What are the staff retention rates between models or if a range of models are accessed?
- How confident are practitioners in managing a scenario which includes risk and uncertainty with supervision vs no supervision?
- How has the organisations staff survey altered in response to introduction of a model of supervision?
- Can we demonstrate that those who experience supervision continue to create their own personal supervision opportunities in the future?
- Does group supervision Vs Individual supervision improve outcomes of supervision?
- Is supervision better delivered at peer level?
It is critical for successful implementation of a workforce strategy that clarity on the nature of supervision is needed.
The Clinical Supervision Evaluation Project (CSEP; Butterworth et al. 1997) utilise The Manchester Clinical Supervision Scale© (later the MCSS-26©; Winstanley & White 2011) but has not been developed to consider the elements of inclusion, shared perspectives, freedom to speak up and complex decision making.
In recent times, supervision has become used as a term for coaching, mentorship, peer review, competency assessment, preceptorship, clinical teaching, buddying, debriefing and other oversight encounters. Not uncommonly, it has involved ‘personal performance review’, case review and even therapy.
In addition, organisational culture and supervision interface in how the confidential nature of supervision has to acknowledge the contexts of a ‘duty of candour’ and Freedom to Speak Up, which may or may not be trusted
What do our practitioners consider important?
Supervision is a resource that people feel is poorly delivered and rarely use as a safe space to explore how the flow of experience leads to a state of arousal, our emotional response and enables decisions to be made through intuition and pattern recognition, alongside critical thinking and judgement.
It is important to explore these aspects as much of this occurs at an unconscious level and interestingly rather than becoming more confident and resilient through experience, evidence suggests we are overwhelmed and unhappy.
Situational Decision Making has been included in the NHS People Profession Map https://peopleprofession.cipd.org/Images/full-standards-november-2022_tcm29-112150.pdf and The Messenger Review: Leadership for collaborative and inclusive future explores skills required for our practitioners. https://www.gov.uk/government/publications/health-and-social-care-review-leadership-for-a-collaborative-and-inclusive-future/leadership-for-a-collaborative-and-inclusive-future.
The other consideration, which should be addressed in the model choice for supervision is how this could support the loss of experienced staff and their contribution to complex decision making and regain the insight that has been lost to enable our junior colleagues to ‘catch up’.
Nurture Model of Supervision
With skilled facilitators of supervision, we have opportunities to create new models of delivery and would consider anyone interested in this topic explores Ian McGilchrist work: https://channelmcgilchrist.com/home/ which considers insight, intuition and imagination.
Our Nurture model of supervision has built on Models of Reflection (Gibbs), Seven Eyes and restorative clinical supervision, alongside reflexivity and psychological safety to explore how to make decisions where there is risk and uncertainty.
Our model explores the four types of knowing:
- Propositional (facts)
- Policies and Procedures
- The perspectives of others
- Context, intuition and imagination
In addition, we consider connection, arousal response, emotions and empathy by understanding how we think and feel, how others think and feel and respond to distress with compassion for ourselves as well as others.
This allows us to understand context, value intuition, respect other perspectives, celebrate uncertainty and create a workforce that can manage risk feeling confident to apply strategies and achieve goals.
In the Matter with Things (2021), McGilchrist raises many fascinating points which are relevant to expertise and practice. McGilchrist’s research is focused on the role the left and right hemisphere of the brain play in human existence. The left side likes procedures and processes. The right side of the hemisphere is concerned more with context and establishing the bigger picture. Synthesis of these two sides, enables us as human beings to make sense of our surroundings, and work out what to do.
When we discover and try something new, we use the right side of the brain. The new situation requires us to draw from our intuition, what does this experience feel like, what feels right and what feels wrong. We use our imagination to try and make sense of the situation and how we could effectively participate with it.
As you became more proficient the left side of the brain becomes more dominant. You develop routines based on what works well and what doesn’t. You do not need your imagination and intuition because you know what will happen.
We need however to ensure that expertise does not become our automatic default, as we will miss cues and should attempt to use our imagination regardless of our familiarity with situations. We must always ask of ourselves and others, what else could this be? Does this feel right or wrong? If we do, then the mind is likely to remain far more receptive to the external environment, and we’ll be using both hemispheres of brain.
So lets explore models of supervision to provide creative solutions to retain our workforce, enabling them to be confident practitioners, who enjoy exploring and documenting their thinking in relation to risk and uncertainty and find new ways of practicing.
Lets celebrate using our imagination.
