Clinical Supervision

‘Supervision is a dynamic, interpersonally, focused experience promotes the development of therapeutic proficiency. One of the primary reasons for all supervision is to ensure that the quality of therapeutic intervention with the client is of a consistently high standard in relation to the client’s needs. Consequently, supervision must be acknowledged as a conerstone of clinical practice’.

What is clinical supervision?
Supervision is the term used to describe planned regular periods of time that superivisor and supervisee spend together discussing the supervisee’s work and learning progress. Supervision is a multi-dimensional process which should provide the following functions:
To evaluate performance
To monitor levels and priorities of workload
To individual case review.
It should provide a forum to assess the nurse/patient relationship and professional development. It should be supportive and motivational, educative and modelling. Clinical supervision looks at the nurse’s behaviour within the nurse patient relationship.

Why do we need supervision?
Wright states, ‘It seems logical to assume that if nurses are to treat patients as human beings, they in turn need to be treated in the same way by those who manage and educate them. If nurses, through reorganising their working patterns and permitting partnerships with patients, are to have their traditional props pulled from under them, then they need help to find new ways of coping’.
Firth et al conclude from their study that receiving supervision contributes significantly to reduce emotional exhaustion among nurses. Sullivan has found that ‘if the experience of stress is not alleviated .. the consequences for nurses are problems with maintaining standards and quality of care offered to patients’.
Supervision gives us the means to develop professional skills and judgement, and a commitment to achieving professional growth in order to improve the standards of service.

Supervision arrangements
Arrangement for supervision should be agreed between supervisor and supervises, and formalised in either verbal or written contract covering:
Job descriptions, policies and priorities
Supervisor’s expectations
Supervisee’s expectations
Team expectations.
When negotiating contracts, the following should be taken into account:
The focus
The content
The methods
The arrangements.

Role of supervisor
As defined by the English national Board, supervisors are ‘first level nurses, who are appropriately qualified and experienced and have received some preparation for the role’. Supervisors can also be other mental health professionals who have some training, and experience in supervisory skills. Wilkin identifies the following as skills required by the supervisor:
Communication skills - ‘To be attentively and actively, listening and being able to comment openly, objectively and constructively’.
Supportive skills - ‘To be able to identify when support is needed and offer supportive responses’.
General skills - ‘Specific knowledge of mental health nursing’.
Specialist skills - ‘Nurses who specialise in particular therapies or fields of work should have access to supervision by someone who is similarly orientated’.
Supervisors must be able to meet with other supervisors, to continue to improve their own skills.

Rust states that ‘it is important that anyone who undertakes the role of supervisor should clarify any feelings on what is to be achieved’.

Clinical supervision in practice
Harker suggests that there are several ways that supervision sessions can be organised:
1. ‘Peer supervision, either on a one-to-one basis or within a small group setting. The obvious advantage is that the universal identification provided by peer supervision provides a sound platform from which to launch supervised sessions. The team leader or manager’s role in peer supervision is purely as a monitoring exercise. They would not be included in the actual supervision session’.
2. ‘Team supervision, which involves focusing on the team objectives as opposed to individual work. Usually facilitated by one identified supervisor.
3. ‘Shadow supervision. One nurse, possibly a student or a newly appointed nurse undertaking an induction programme, is attached as a shadow to an experienced nurse, to learn by observation’.
4. ‘Managerial or tutorial supervision. The team leader supervises an individual nurse formally and privately’.
5. ‘Pair supervision, which involves two nurses being supervised by their team leader or manager’.
6. ‘Live supervision. Supervision can also be carried out in vivo, during the actual nurse/patient meeting, after which it is discussed between supervisor and supervises. The supervisor is able to obtain a clearer view of the process occurring between the supervises and the patient.

Identifying the types of supervision required should be carried out in conjunction with the supervisee, and in the light of their professional development and service requirements. All supervision should be continuously evaluated for effectiveness. For these types and processes of supervision to be effective, there must be mutual trust and respect between supervisor and supervisee.
Supervision should cover the following four principal areas:
Clinical work
Professional standards
Personal growth and development
Evaluation of work performance.

Wolsey identifies the following as the basic skills required in supervision:
Exploration
New understanding
Skills development
action.

Limitations
Managerial supervision on its own will possible over-emphasise standards at the expense of support. Managers have a disciplinary role, which may influence the supervisee’s willingness to share aspects of themselves. This type of supervision can ensure standards are maintained and developed.
However managers many be remote from clinical issues, making skills development difficult.
Peer supervision may have a tendency to over-emphasise support. Peers may collude in not challenging each other, and may have little to offer in terms of skills development and ensuring clinical standards are met.
Non-managerial supervision is able to identify skills development and offer support, but may have little influence on poor standards.
Live supervision may foster dependence on the supervisor always to be there and bring the answers with them. It may not always encourage independence in the supervisees.

Recommendations
Clinical supervision is a model that must continue throughout professional life, thus providing a supporting as well as an educative purpose.
Currently, supervision is often carried out on an ad hoc basis, and types of supervision offered vary across the country. Supervision must become a part of every mental health nurse’s working week.
Careful consideration should be given to the qualifications, skills and experience required of supervisors, and to their ability to meet the individual needs of the supervisees. All supervisors should have the opportunity to receive training and learn skills that are constructive and supportive. All supervisees should have the same opportunity to learn about their role.
Supervision should be available to all practitioners, regardless of seniority. All supervisors should also receive regular supervision, in order to monitor and develop the quality of supervision.

This paper was originally published in Mental Health Nursing, Volume 15, Number 1, January 1995. The original paper was produced by the Association’s Care and Practice Group.