British Airways (BA) carries an estimated 40 million passengers each year to more than 200 destinations worldwide. The company employs 46,000 people, of which 40,000 are based in the UK.
British Airways Health Services (BAHS) is based at BA headquarters in Harmondsworth, near Heathrow Airport, with a smaller department at Gatwick Airport. BAHS is a multidisciplinary team responsible for the delivery of OH services and other interlocking and vital functions (see box on page 25).
Health provision at BA has a long history, with its roots in the company’s forerunners ‘British Overseas Airline Corporation’ and ‘British Imperial Airlines’, however, any traditional aspects of the service lie firmly in the past.
In 1997, in direct response to cost reductions throughout the company and following a full role review of the service, radical changes to the structure of BAHS were made. All BA support departments were required to be more business focused and to add real value. Attention was given to the type of OH service the company needed and what BAHS was then providing and would need to provide in the future. Following the role review, changes impacted radically on the entire multidisciplinary team – most significantly, the nurse group.
Occupational health services (OHS)
Prior to 1997, the OHS was a traditional, mainly clinical service based at 12 treatment centres located at Heathrow and Gatwick Airports. Kitson (1999) writes that nurse training teaches the essence of the traditional nurse model and patient advocacy.1 Before 1997, OH provision at BA mirrored this model and was not fully aligned to the main needs of the business or concerns of management. It was fundamentally reactive, with nurses routinely working to local policies, procedures and standing orders.
Following the review in 1997, the role of OH adviser (OHA) was introduced. It was the catalyst to new ways of working, moving away from the predominately traditional-based treatment service to one that was streamlined, efficient, and business focused.
Nurses with the appropriate qualifications, and from the original clinical nurse group, were appointed as OHAs. Their brief was to work proactively with managers throughout the business to help reduce sickness absence and advise on occupational health and safety issues.
The new structure required practitioners to increase their autonomy, have confidence in problem solving and decision-making, and to take a more proactive approach to service delivery. This would require creative thinking,2 analysis of practice,3 interpreting medical reports and making evidence-based judgements.4 Running parallel with any decision-making, OHAs would need to use an element of intuition,5 and unconscious competence.6,7 Intuition, an element of unconscious competence, occurs when a well-practised skill becomes automatic and can be operated ‘while the conscious mind is elsewhere’.6 On reflection, it became evident to some of the group that they did not have the luxury of years of proactive OH experience to help with difficult decision-making.
In response to this need, and to meet the expectations of the OHA role and for some, to act as a refresher, a comprehensive internal four-week training programme was designed and undertaken. Despite the knowledge and skills attained during this course, the transition to advising on complicated sickness absence cases proved challenging. It required combining difficult decisions and problem solving, with the complexities of adding value to the business and balancing advice to managers and employees. Decisions and advice was often further complicated by very real air and ground safety issues. Despite working in a large team, these challenging times ultimately highlighted the potential isolation of the OHAs in their work.
Within OHS, various avenues of support, such as head of service, line managers, peer group, physicians, were available. However, anecdotal evidence showed that it was the peer group that was most frequently used for support in case management issues. For the majority, this was on an ad-hoc basis, such as ‘catching colleagues on the hop’ or over coffee. Although functional, it was recognised that a more reflective and structured approach available to all nursing groups was required.
The changes within the clinical nursing service were less dramatic. Health centres were amalgamated into two sites. Although a small treatment service remained, screening, first-aid advice and health promotion became the main focus. The support for OH nurse practitioners (OHPNs) was provided mainly by the senior OH nurse practitioners (SOHPNs), and again via peer discussions.
Initial thoughts led some of the OHA team to believe that counselling would be a panacea to their identified difficulties. However, during this period there was an increased understanding within general nursing of the role of clinical supervision. The position statement of the governing body of nurses, midwives and health visitors outlined the key principles of supervision in nursing (UKCC, 1996) and defined how supervision supports nurse practice, education and competence, providing a platform for professional development. Clinical supervision was seen as a tool to provide support, gain expertise and safeguard standards.
In April 1999, BAHS appointed a new head of OHS who had several years experience of supervision and who had worked with the AOHNP (UK) in developing guidelines on Clinical ‘Professional’ Supervision.8 The concept of clinical supervision was now more formally introduced and the prospect of this being a plausible solution to enhance existing support became a credible reality, not only as a support mechanism but also as a professional development tool.
Professional supervision in BAHS: the consultation
The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC – now the NMC) did not take a prescriptive stance in how clinical supervision should be adopted.9 It acknowledged a need for a range of related models and processes to address the needs of the differing nursing specialities, while maintaining its key principles. Such a process customised to the needs of the nursing group in BAHS was outlined in a guidance paper Professional (Clinical) Supervision10 (see box on page 24).
If adopted, supervision in BAHS would provide structured and protected time to give an opportunity to discuss issues arising from working practices. These might include thoughts, feelings, complexities and supporting issues related to problem solving and decision-making.
The objectives of professional supervision for the OHS included:
- Enhancing decision-making andproblem-solving skills
- Increasing self-awareness
- Encouraging professional growth
- Providing greater insight intocontemporary practice issues
- Encouraging lifetime learning
- Nurturing and sharing best practice in a safe environment
- Safeguarding standards
- Supervisees feeling valued andsupported
- Encouraging teamwork
- Providing opportunities forbenchmarking and networking.
The guidance paper outlined the difference between professional supervision and managerial support, and became the driving force, which led from the notion of clinical supervision to the reality of ‘professional’ supervision as defined by AOHNP.8 On the recommendation of the head of the OHS, it was agreed that ‘professional supervision’ was more descriptive of the roles within BAHS, which for many are predominantly advisory, with some clinical function.
Within the nursing group, only two people had participated in formal supervision or training. The document, together with meetings and presentations to groups of nurses, initiated a consultation process within the OHS team. So began the journey along the path from novice to expert.11
A steering group was formed to communicate with the wider team to:
- represent all viewpoints of thevarious OHS team members
- offer a broad spectrum of opinion
- feedback to the various OHS team members
- support and encourage a positiveapproach to supervision
- facilitate the process of supervision.
Figure 1 summarises the advantages, disadvantages and individual concerns identified during the consultation period. The members of the steering group were encouraged to promote the positives of professional supervision and to look at ways of addressing and overcoming any negatives identified. Opinion was canvassed regarding the perceived benefits of professional supervision and how it could be adapted to the department’s needs and at the same time address any individual concerns.
Best practice
An exploration of best practice concerning professional supervision within OH nursing was carried out. This consisted of networking within the AOHNP, the RCN OH Managers’ Forum, and with colleagues from other organisations. From this exercise, it was concluded that very few organisations in OH had a formal supervision programme in place. Those that did used external supervisors, mainly from a counselling or psychiatric nursing background. Other discussions and reading revealed that ‘external’ might refer to a facilitator outside the field of the speciality, in this case, OH.12
Facilitation
The guideline document identified a requirement for group supervision facilitated by an external supervisor with relevant OH experience and knowledge.10 The box below summarises the preferred attributes of a supervisor for BAHS.
As with the findings of Maynard (2003),12 choosing a supervisor with OH experience appeared to be very important to the BA group. In reality, such supervisors can be hard to find. Other options considered included one-to-one, peer group, group facilitation, ‘supervision on line’ (supervision with an external colleague either via telephone or internet), and developing its own supervisors and entering a reciprocal arrangement with another OH service.
These alternatives were explored via the steering group. From a service and resources viewpoint, it was concluded that none of the options considered were feasible – for example, the infrastructure for supervision online was not in place. Nor had any other OHS of similar size or at a similar stage in the introduction of clinical supervision been identified. From a resource perspective, one-to-one supervision would be costly in both time and monetary terms. The search for an external supervisor to facilitate group supervision continued. In the meantime, the focus turned to training needs.
Training
Maynard (2003) identifies several barriers to professional supervision.12 The OHS appeared to be facing similar barriers: finance, major down turn in the industry and a lack of skills required to provide and receive supervision.
To prepare the team amid these difficulties, training for professional supervision, as recommended by AOHNP,8 was explored and a needs analysis performed. The analysis identified that training would need to be tailor-made to the development of the varied skills required by the individual practitioners and to be realistic in the current business climate.
The box on page 28 summarises the training needs identified by the group as critical to the success of the professional supervision programme.
During this preparation, the airline industry experienced many further challenges. Streamlining of the business in response to these resulted in more limited funds for professional supervision and the required training, so the OHS needed to be creative in meeting these needs. The training would not be viewed as ‘one-off’ or ‘stand alone’, but as part of continual development.
The model of learning chosen was that of ‘blended learning’,13,14 incorporating internal and external resources, with the emphasis on self-directed learning and computer-based training.
Advantages of ‘blended learning’ include:
- Allows the learner to match their learning experience to theirpreferred method of learning
- Allows learning to be scheduled around work commitments
- Provides variety and interest throughout the programme
- It is an effective way of making useof all resources available
- It is practicable, accessible andappropriate.
A disadvantage for some is that the majority is based on self-directed learning. However, blended learning suited the philosophy within the organisation, that is, where possible, to move all training to e-based learning.
The training department and the OHS managers worked together to produce a workbook to guide the learning process and assist individuals in identifying their training needs and plan how to meet them.
The programme was based on self-directed learning, using internal training resources and training by an external educator specialising in professional supervision. Components of the programme are shown in the box on the right.
It was deemed that the training would provide opportunities for personal development and would be used alongside the existing performance management system. It was decided to proceed with the training programme even if professional supervision was never introduced, as it would provide personal and professional development opportunities for the OHS group and was seen as adding value to individual and team performance.
Following the training, feedback from practitioners was positive and resulted in a change of perception for some, helping to move practitioners forward on the continuum towards lifelong learning. Training enabled the majority to recognise that professional supervision is something that enhances practice and that there could be several alternative ways of implementing it within the department.
Where is the team now?
It has been a long journey. However, perseverance has paid off. The OHS is now in the favourable position of having secured an external supervisor to facilitate professional supervision. Although it has taken a considerable time to finalise, this is a step forward in OH practice. It is hoped that the previous consultation work and training will provide good foundations on which to build an ongoing programme.
A three-month trial of six-weekly sessions was planned and has now been completed. A model of supervision similar to that advocated by Proctor (1986)15 has been used to provide the supervisees with ‘protected time’ for support, development and education through the process of reflection.
The sessions fulfilled the functions of:
- Support (restorative)
- Skills enhancement and education (formative)
- Consistency in standards andperformance (normative).
To address everyone’s needs and to firmly separate performance management and professional supervision requirements, the OHS managers and SOHPNs were supervised in two groups, separately from the main nursing group.
This main group of OHAs and OHNPs were randomly sub-divided into six groups of five. These six groups received three supervision sessions over a three-month period.
The managers and SOHPNs each received only one session facilitated by the external supervisor to enhance their skills. The aim thereafter was that they then formed self-facilitated peer groups and results could be compared. In peer group supervision, group members are supervisors to each other.16
At the end of this three-month period, an evaluation took place. This was to canvass views, to ascertain whether or not individual expectations have been met and identify the benefits gained and how to proceed in the future. The evaluation was conducted via the steering group and through formal audit by the supervisor. Results showed that the overwhelming majority found supervision a positive experience and that they wished to continue.
The ideal would be to continue the sessions with an external supervisor. In the long-term, the reality is that for mainly business reasons, this may not be feasible. Ultimately, BAHS may wish to consider preparing several OHS staff to become supervisors and to then enter a reciprocal arrangement with another organisation. Anyone out there interested?
All three authors work with British Airways Health Services. Debbie Billington is an OHS team manager, Angela Robinson is an OHA, and Carmel Hallinan is an OH practice nurse. For more information, contact e-mail [email protected]
References
1. Kitson, A (1999) ‘The essence of nursing’, Nursing Standard 13(23) 42-46
2. Kuhar, M (1988) ‘Critical thinking’ a framework for problem solving in the occupational health setting, American Association of Occupational Health Nurse Journal 46(2) 80-81
3. Taylor, AM (1997) Analysis of Practice: Techniques & Strategies, European Nurse 2(1) 17-22
4. Bradshaw, PL (2000) Evidence-based practice in nursing – the current state of play in Britain, Journal of Nursing Management 8 313-316
5. McCutcheon, HHI and Pincombe, J (2001) Intuition: an important tool in practice of nursing, Journal of Adv. Nursing 37(3) 342-348
6. Turnbull, J (1999) Intuition in nursing relationships: the results of skills or qualities, British Journal of Nursing 8(5) 302-306
7. Rosenoff, N (1999) ‘Intuition comes of age’, American Association of Occupational Health Journal 47(4) 156-161
8. AOHNP (UK) (2001) Guidance on ‘professional’ supervision, Published by the Association of Occupational Health Practitioners
9. UKCC (1996) Position statement on clinical supervision for nursing and health visiting, London: UKCC
10 Cook, JA (2002) Professional (Clinical) Supervision – unpublished
11. Benner, P (1984) From novice to expert: excellence and power in nursing practice, Addison – Wesley
12. Maynard, L (2003) Under supervision, Occupational Health June 23-26
13. Sing, H and Reed, C (2001) A White Paper: achieving success with blended learning, American Society for Training & Development, March, p1-11
14. Bersin, J (2003) What works in Blended Learning, http://www.learningcircuits.org/2003/jul2003/bersin.htm
15. Proctor, B (1986) Supervision: a co-operative exercise in accountability in Marken, M and Payne, M (eds), Enabling and Enduring, Leicester, National Youth Bureau/Council for Education and Training in Youth & Community Work
16. Bond, M (2003) Workshop notes – unpublished
BAHS: The directorate
- Occupational health services: a nursing group of a management team, occupational health advisers (OHAs), senior and occupational health practice nurses (SOHPNs), and occupational health practice nurses (OHPNs).
- Occupational and Aviation Medicine: a medical team of consultant occupational physicians
- Business Support
- Passenger Medical Clearance Unit
- Dental Services
- Food Safety and Environmental Health
- Travel Clinics
BAHS mission: To provide the highest quality health services in support of British Airways’ Corporate Mission
BAHS goals:
To provide the best advice and assistance to the company, its staff and customers on:
- fitness for work and prevention of work-related ill health and sickness in ground, air and overseas environments
- compliance with accepted standards and legal requirements in relation to occupational health and safety
- health-related matters associated with airline operations
OHS’ objectives relate to:
- Attendance management
- Fitness to work and rehabilitation
- Health and safety and risk management
- Emergency planning
- Advising on arrangements for first aid
- Health promotion and health education
- Quality and audit
- Evidence-based practice
Figure 1
Advantages
- Team approach
- Evidence for portfolio
- Positive impact on team morale
- Impact on recruitment
- Professional development and opportunities for learning
- Formal process with professional support
Disadvantages
- Resource issues
- Commitment
- Scepticism
- Confidentiality issues
- Varying levels of knowledge
- Time constraints
- Financial implications and limited resources
- Effect on service delivery
A blended learning programme for professional supervision
- Workbook – to provide a guide and details of learning support available
- Personal professional supervision development plan
- Self-directed learning
- E-learning – for example, problem solving; assertive participation at meetings
- Skill-byte sessions – for example, giving and receiving feedback
- Directed/supported learning (external educator) – to deepen the understanding of professional supervision and provide greater insight to the practicalities of supervision
- Team working: ‘Cave Rescue Exercise’ – illustrates the differing values and attitudes that individuals bring to groups and how this can influence problem solving and decision making
- Library resources
Training needs analysis
COMMUNICATION
- Questioning
- Listening
- Making a point positively
- Summarising
- Reflection
INTERPERSONAL SKILLS
- Group dynamics
- Resolving conflict
- Giving and receiving feedback
- Self-awareness
- Emotional intelligence
ACTION PLANNING SKILLS
- Contracting
- Objective setting
- Decision-making
- Creative thinking
- Problem solving
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MENTORING
- Coaching
- Mentoring
SUPERVISION
- Models of supervision
- Role of supervisor
- Being a supervisee
- ‘Demystification’
- Exploring the supervisory relationship between the supervisor and supervisee
