Under supervision

Clinical supervision is a valuable concept for safeguarding
practice standards, as well as a formal process of professional support and
development. But, how can we effectively assess its successful delivery?  By Linda Maynard

Clinical supervision, formally introduced by the United Kingdom Central
Council For Nursing, Midwifery and Health Visiting (UKCC) position statement in
1996, is seen as a valuable concept for safeguarding practice standards, as
well as being a formal process of professional support and development.1

This UKCC paper provided an outline of key principles of supervision rather
than a prescriptive stance for all nursing specialities.

The earlier Vision for the Future paper saw supervision as a means of
encouraging self-assessment, and building analytical and reflective skills.2

But how can we assess if the supervision is being effectively delivered to
provide benefit and value to the practitioner and the workplace?

One of the key elements is in exploring the supervisory relationship between
the supervisor and supervisee. This association formed the basis of the
following Masters research study.

The practice of supervision

The introduction of supervision into general nursing has been slow, and this
has been mirrored in occupational health. Various barriers have been
highlighted, such as time, money and lack of training in the skills required to
provide and receive supervision.

In occupational health (in common with many other specialist areas in the
community), the OH practitioner – particularly those working in isolated roles
– may need to look outside their own profession for supervision.

As Johns suggests: "…in different hands, supervision can become
different things depending on the intent and emphasis of the supervisor."3

Current research suggesting that supervision is beneficial and valuable is
growing in evaluative literature, but few studies have been able to link the
benefits to the practitioner and the clients directly. The need for more
empirical evidence is clear, as is the necessity to research the quality and
nature of supervision given.

This study was therefore completed with the assumption that supervision has
positive benefits, while remembering that: "…researchers evaluating
clinical supervision have been like the critic who reviews a production on the
basis of the script and applause, not on the actual performance."4

The qualitative study outlined below looked at what practising OH
practitioners thought was an ‘appropriate’ supervisory relationship.

Reflective practice

The dominant, guiding theoretical framework in use when supervising is
Proctor’s three-function interactive model. This has three elements:
restorative (supportive), formative (skills and educative development) and
normative (awareness and adherence to standards).5

Part of understanding the OH practitioners’ perceptions in this study was to
understand if a supervisor in any OH setting could facilitate all these
elements. Supervision also helps reflective practice by examining an experience
or issue.

The research question was: Can the characteristics of an appropriate
supervisory relationship be identified to meet the functions of clinical
supervision in OH practice?

The aim was to utilise perceptions and personal views arising from
experience of supervision to move the practice forward, and add to knowledge
that already exists about the role of the supervisor.

The objectives of the study are:

– Describe the supervisee’s experiences and interpretations of the function
of supervision

– Explore views concerning the amount of specialist knowledge needed to
supervise OH nurses

– Examine views regarding relevant experience, training and background to be
an OH supervisor

– Identify specific supervisory skills needed to facilitate reflection on
practice.

The study

For the purposes of the study, OH practitioners who were in, or had
experience of, supervision were invited to be participants. The range of
employers was diverse and some were receiving supervision from professionals
external to the OH field.

A semi-structured interview schedule was formulated, including the key areas
considered to be important.

This was developed from two main studies that had previously looked at
supervisor characteristics and the elements of good supervision.6,7

The interview included the need for biographical detail to understand how
long each interviewee had been in OH practice, what their formal OH
qualifications were and their previous experiences of supervision.

The Proctor framework, described earlier, was used to explain the functions
of supervision, and specific supervisory behaviours were introduced, dependent
on the dialogue – namely those classified by Bond and Holland.8

As a purposive sample was required of OH practitioners, the researcher
advertised for participants. The fact that supervision appears not to be widely
practised in OH or may not be of a predictable quality, made sampling
potentially limited. However, the final eight participants represented the fact
that sample sizes tend to be small in qualitative research and large samples
are not always equated with richness of data.

The pre-test interviews showed that the OH practitioners required a
description of the Proctor model to be able to talk about whether these
elements were being met.

All those taking part agreed to be taped and the data from the interviews
was transcribed in full.

Data analysis

Thematic content analysis was used to produce systematic recordings of the
emerging themes.9 A final list of categories and sub-headings were selected and
returned to two of the volunteers to check the appropriateness of the process.

The analysis was completed in the context that supervision is an accepted
practice in nursing and that the participant’s thoughts and perceptions were
aligned with this fact.

Findings

Seven woman and one man were interviewed for the study. Experience in OH
ranged from two years to 24 years, and all participants had qualifications in
OH apart from one. Five worked in the NHS, and the remainder for private
organisations, one of whom was self-employed. The practitioners outside the NHS
were in isolated practice (two, all of the time), while the NHS practitioners
worked mainly in small teams.

The length of time in supervision ranged from one practitioner who had only
a few sessions, to one with four-and-a-half years’ supervision. Five of the
participants receive or had received supervision from another OH practitioner
(three described the relationship as ‘peer’), and the remainder received
supervision from a counsellor and senior NHS nurses from another speciality.

The findings fell into eight categories with sub-themes:

– Interpretation of clinical supervision in OH practice

This was necessary to understand the respondents’ views and comments about
their perceptions of the supervisor role. Generally, the ‘reflective practice’
concept was not named, but most individuals seemed to be practising reflection.
They all shared the view that supervision can provide an opportunity for
exchanging information, checking out practice, challenging and being
supportive.

This appears to fit with the general aims of supervision in the literature,
with the main use being to fulfil the ‘formative’ function – that is, the use
of supervision primarily to share information and ideas.

– The importance of supervision for isolated OH practitioners

The necessity to have a supervisor who would help guide practice and provide
reassurance was clear. As one respondent stated: "Nobody is an island, and
you can’t work on your own all the time."

– Experienced supervisors

Experienced supervisors were considered important whatever the background,
and needed to be dynamic in their own practice. Peer supervisors were viewed as
complementary to the supervisee’s own experiences, particularly when swapping
supervisor/supervisee roles.

– The nuances of OH practice

Choosing a supervisor who understands OH practice appeared to be very
important to respondents, particularly during OH training and as a
newly-qualified practitioner. The reasoning for this fell into two themes: the
need to understand the OH role and the working environment so as to understand
practice and professional issues; and to meet the evolving needs of the OH
practitioner. After a suitable period, some respondents felt a supervisor from
another discipline may be useful.

– ‘External’ supervisors

This meant choosing a supervisor who is outside the speciality of OH; they
may be employed in the same organisation but do not have a background in OH.

The main benefit appeared to be in discussing issues in depth and the
supervisor having an objective stance on problems.

This was summed up by one interviewee, who said: "…an external
supervisor can take themselves into our speciality but with a different
dimension to it. It’s a bit like a diamond, as you turn it around you get a
different facet with the light coming through."

– Personality of the supervisor

The need to be ‘in tune’ and on the same wavelength was essential, as a poor
relationship between supervisor and supervisee was generally felt to be un-
productive, no matter what background, experience or knowledge the supervisor
brought with them.

– Expectations of the supervisor knowledge base

This varied, depending on the needs of the supervisee. A good, varied
knowledge was considered to be important, the key element being that
supervisors were aware of their own boundaries.

Having a good current knowledge base was essential, as was an understanding
of the culture of the organisation and business world. The supervisor must also
be able to acknowledge their own limits and be prepared to continue developing
him or herself.

– Expectations of facilitative skills

These fell into three broad categories, which not only listed appropriate
skills but also emphasised the need to know the OH practitioner, and be able to
balance and develop the supervisory sessions.

Understanding and trust was an important basis on which to build the
supervisory relationship.

The specific skills of enquiry: listening, being open minded,
non-judgemental, dependable; facilitating, empathetic, and realistic were
listed, as well as the skill to balance the session to include all three
elements of the Proctor model (restorative, formative and normative).5

Discussion of results

The objectives were met in the study, with the exception of ‘identifying
specific skills needed to facilitate reflection on practice’.

Some specific skills were highlighted, but there unforeseen need to
understand how the concept of supervision in OH practice is structured arose
(that is, which theoretical base is in use), before looking further at specific
skills.

The interviewees displayed some blurring in what they interpreted as
supervision. The supervision functions were unclear and vague. In the main, the
sessions were being used to exchange information, share learning and support
the supervisee. There was some evidence of the supervisee monitoring their own
effectiveness, assuming responsibility for their own practice and developing
professional insight, but, generally, participants appeared to be practising
non-threatening supervision.

This is supported in the literature, particularly by Johns, who argues that
many practitioners have been unable to accept responsibility for their own
practice and feel more comfortable where their work is ‘checked’ or their
practice is ‘insured’ by agreeing a policy, or taking a directive approach.10

The ‘normative’ function of supervision

The study results showed that not all three elements of Proctor’s
interactive reflective model appeared to be in common use.

The restorative (supportive) and formative (educational) elements were
demonstrated, but the normative aspect was absent in many cases.

This is the function that looks at the ‘quality’ of supervisee practice
compared to the standard. It may be that this element is confused with management
control and, as such, is confused with ‘management’ supervision or appraisal.5

Whatever the debate about the function of supervision, the normative facet
was established to recognise the limitations of practice within the norms and
rules of autonomous practice.

In this study, as is the case in everyday OH practice, the practitioners
were working in diverse areas, each with its own norms and rules.

In reality, the gap between actual and desirable practice may not be clear
or standards may be tacit or unexplored. This makes the normative aspect
difficult to incorporate in supervision.

Nevertheless, this element of supervision would appear to be useful for some
– if not all – autonomous OH practitioners, particularly in isolated roles, to
reflect on the quality of their work as professional standards and benchmarks
are being formulated.

The supervisory relationship

The experience of the supervisor versus their supervisory skills is big
debate in itself. However, the two OH managers who took part in this study
appeared to highly value supervisory skills, and had external supervisors.

Other participants felt only OH practitioners should supervise.

One possible conclusion from this is that the existing lack of clarity about
the role and purpose of supervision may lead to a false belief that only OH
practitioners can supervise other OH practitioners.

The diversity of the OH role also complicates this debate, because the need
to understand the OH role was another strong theme.

Some participants felt having a supervisor with an expertise in OH might not
be as important as the practitioners themselves developed. No-one raised the
other issues highlighted in the literature concerning cross-disciplinary
supervision, such as possible problems with OH jargon or issues of professional
accountability.

The supervisor’s personality was considered very significant and previous
research supports this view. Also, previous studies support the results of this
study, which found that participants felt supervisors should have a wide
professional knowledge.

A contradictory argument is that the supervisor does not need to be an
expert in the profession and should help supervisees to learn for themselves.11
Certainly, for experienced OH practitioners, supervision may not be about
increasing knowledge but allowing existing information to be deepened.

Lastly, the facilitative skills described by the respondents were very
general. It is unclear how supervisor skills are developed and refined, and, in
reality, a mixture of skills and personal attributes may be required for
different situations.

Recommendations

Because the function of supervision was found to be ambiguous, the
characteristics of an ‘appropriate’ supervisory relationship cannot be clear.

While uniformity of approach may be difficult in a diverse speciality such
as OH, an adaptation of the Hawkins and Shohet framework of the different
levels of supervision, would appear a logical way forward to enable an
evaluation based on a suitable theoretical model.12

The right ‘phase’ of supervision could be chosen, with an ‘appropriate’
supervisor and structured approach, dependent on the supervisee’s needs. For
example, a more directive approach may be required for OH students, because the
supervision will be more standards based, probably being supervised by a
qualified, practising OH adviser.

As the supervisee develops, he or she will become more autonomous and have
greater professional insight, until they reach the ‘mastery’ phase. They also
need to develop the ability to adapt. The choice of supervisor will depend on
the individual’s needs, but they may choose a supervisor who is a peer or
external to occupational health.

With further research, it may be possible to demonstrate if the ‘normative’
element of supervision is required for more senior, experienced practitioners.
Appropriate supervisor ‘helping exchanges’ or skills for different levels of
supervision are a logical development.

In the meantime, this study has suggested that good interpersonal and
facilitative skills are important as a basis for effective supervision.

Linda Maynard, MSc in Occupational Health and BSc (Hons) DOHN, is an
independent OH practitioner

References

1. UKCC, 1996, Position statement on clinical supervision for nursing and
health visiting, London, UKCC

2. NHS Management Executive, 1993, A vision for the future: the nursing,
midwifery and health visiting contribution to health and healthcare, London,
Department of Health

3. Johns, C, 1996, The benefits of a reflective model of nursing, Nursing
Times, 3 Jul, Vol 92(27), 39-41

4. Sloan, G, Illuminative evaluation: evaluating clinical supervision on its
performance rather than on its applause, Journal of Advanced Nursing, Sept, Vol
35(5), 664-673

5. Proctor, B, 1986, Supervision: a co-operative exercise in accountability,
Enabling and Ensuring, by Marken, M C and Payne, M, Leicester National Youth
Bureau and Council for Education and Training in Youth and Community Work

6. Fowler, J, 1995, Nurses perceptions of the elements of good supervision,
Nursing Times, May, Vol 91 (22), 33-37

7. Sloan, G., 1999, Good characteristics of a clinical supervisor: a
community mental health nurse perspective, Journal of Advanced Nursing, Sept,
Vol 30(3), 713-722

8. Bond, M and Holland, S, 1998, Skills of clinical supervision for nurses,
Oxford, Open University Press

9. Burnard, P, 1991, A method of analysing interview transcripts in
qualitative research, Nurse Education Today, Vol 11, 461-466

10. Johns, C, 2001, Depending on the intent and emphasis of the supervisor,
clinical supervision can be a different experience, Journal of Nursing
Management, Vol 9(3),

139-145

11. Fish, D and Twin S, 1997, Quality clinical supervision in the health
care professions, Oxford, Butterworth-Heinman

12. Hawkins, P and Shohet, R, 2000, Supervision in the helping professions,
Buckingham, Open University Press

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