by Katherine Schaffarczyk MACN, Nurse Educator, Westmead Hospital, Sydney
Overview of the literature
There is evidence that clinical supervision has been practiced since the early days of Freud, with small groups gathering to discuss and review each other’s work (Carroll, 2007). In the late 19th century in the United States, clinical supervision was introduced for social workers as a supportive and reflective space (Carroll, 2007). Clinical supervision continued to emerge during the 1950s with a shift in focus from a counselling to an educational process during the 1970s. Since the 1980s, clinical supervision has expanded to include Britain and Australia (Carroll, 2007).
Many definitions of clinical supervision exist in the literature. Carroll (2007) encompasses the core of clinical supervision with this definition:
“In the conversation we call supervision…we make meaning of events and behaviours. The method we use to make meaning and sense is reflection – critical reflection. In opening our minds and hearts we begin to perceive, to see, to understand and to make sense of what has been and, in turn, we hope to learn what to do next.”
Despite the vast array of definitions, an agreed definition of clinical supervision in nursing remains elusive. As a result, the successful implementation of a clinical supervision program can be hindered (Robinson, 2005; Cutcliffe et al., 2018). Our experience suggests that the term ‘clinical supervision’ is misleading for what it actually is and reflects, especially to those nurses new to the concept. The need therefore remains to articulate an agreed definition and to gain clarity around the purpose of clinical supervision to further develop clinical supervision within nursing (Cutcliffe et al., 2018).
There are numerous benefits of clinical supervision for nursing staff which include personal benefits such as peer support and stress relief, the promotion of professional development and accountability, and the development of skill and knowledge (Brunero & Stein-Parbury, 2008). The Royal College of Nursing (1999) has identified further benefits which can be categorised as follows:
- Patient focussed: improved quality of care and services; enabling nurses to focus on patient needs; consistent standards in provision of care
- Workforce focussed: lower sickness rates; improved recruitment and retention
- Workplace focussed: better work culture; improved morale; improved risk management.
Our experience of implementing a clinical supervision program
In 2015, the Director of Nursing and Midwifery (DON&M) announced the introduction of clinical supervision into the Transition to Professional Practice (TPP) program for all new graduate Registered Nurses. This was the first time that the value and benefits of clinical supervision had been both acknowledged and actioned in a whole of hospital program. Funding was obtained via the Nursing and Midwifery Office (Nurse Strategy Reserve Funding) of the Ministry of Health (NSW), to train three clinical supervisors through an external provider. The three newly trained supervisors joined with five supervisors who had trained previously; there were some variations in the experience and currency of practice of these trainers, and the methodologies used in their clinical supervision practice.
The team of eight supervisors met to discuss the logistics of the program including the allocation of groups. A PowerPoint presentation was developed to introduce the concept of clinical supervision to the TPP program nurses during their induction to the hospital. The supervisory team collaborated (which included clinical supervisors from Child and Family Health Nursing) to develop a set of guidelines which included a maximum size of 10 nurses per group (due to a total number of 120 nurses) of one monthly session with mandated attendance. Given the duration of the TPP program is 12 months, the program was evaluated at six and twelve months, with a questionnaire at session one to gain insight into the TPP program nurses’ understanding and expectations of clinical supervision.
The supervisory team met regularly during the initial phases of the program to identify any issues and action these accordingly. The number of nurses attending clinical supervision sessions varied between supervisors and across groups. The reasons identified for this included rostering (night duty and days off), annual and sick leave, busy ward, unable to be relieved to attend, staff (including the Nursing Unit Manager in some cases) hesitant to accommodate the nurse to attend, heavy patient load, staffing issues on the ward, forgot to attend and not checking emails. This is despite all key stakeholders (Nursing Unit Manager, Clinical Nurse Educator and nurse) being advised of the dates well in advance. Many supervisors reported a core group of nurses who attended regularly, presumably having identified and appreciated the benefits that clinical supervision was providing to their clinical and reflective practice and professional development. What was important at this time was to ‘keep going’ in promoting and providing sessions and to hope that attendance would increase once the ‘word got out’ via the TPP program ‘grapevine’ as to the benefits of clinical supervision.
Comments received from nurses pre-program varied from some nurses not knowing what to expect to others having a good understanding; for example, a way to debrief/reflect in a safe and supportive environment, share experiences, discuss issues and understand why we do things. Some nurses commented on the need for the environment to be confidential in nature and that they would reserve their comments and participation until satisfied that this was maintained.
Mid-way through the program at six months, comments included increased confidence, an opportunity to reflect on practice and to meet and “bounce ideas off’ peers who understand what you are going through”. There were also benefits seen in “comparing my practice with other points of view and experiences” and “how to deal with similar situations”. This feedback may indicate the intertwining of reflective practice, peer learning and knowledge acquisition.
At the conclusion of the program, feedback demonstrated a mature and deeper understanding of clinical supervision; for example, “the program was giving us a greater view of the workplace and our job”, able to “lay out complex thoughts and worries into logical steps”. These comments also reflect some of the benefits identified in the literature, particularly in regards to professional growth and development.
The nurses also provided constructive feedback on the program which related to the individual; for example, struggling with the model used (preferred the model of debriefing used during undergraduate studies) and those that related to the group; for example, some nurses not being open or sharing experiences. These comments indicate the need to review the process of establishing group rules in session one of the program. As evidenced from the feedback provided by the TPP program nurses, clinical supervision can play a key role in contributing to self-care and personal empowerment through reflective practice in a supportive and safe environment.
Due to the increasing demand for clinical supervision across the hospital, a further four nurses are currently undertaking training. The current supervisory team are very excited that people are now starting to talk about clinical supervision and seek it out. The prospects are equally promising and as a result, strategies to further build capacity for clinical supervision to be made available to all nurses are currently being discussed with the continued support of the Nursing Executive. Clinical supervision into the future will be vital as reflected by Carroll (2007):
“Supervision is for the future. It is to enable supervisees from whatever profession or background, to return to their work more knowledgeable, skilled, insightful and creative, and of more benefit to those with who they work. Supervision prepares the future.”
Brunero S. and Stein-Parbury, J. (2008). The effectiveness of clinical supervision in nursing: an evidenced based literature review. Australian Journal of Advanced Nursing, 25, 3, p.86-94.
Carroll M. (2007). One more time: What is Supervision? Psychotherapy in Australia, 13, 3, p.34-40.
Cutcliffe J.R., Sloan G. and Bashaw M. (2018). A systematic review of clinical supervision evaluation studies in nursing. International Journal of Mental Health Nursing, p.1-21.
Robinson, J. (2005). Improving practice through a system of clinical supervision. Nursing Times, 101, 23, 30-32.
Royal College of Nursing (1999). Look Back, Move On: Clinical supervision for nurses. London.