The effectiveness of clinical supervision for a group of ward managers based in a district general...

The effectiveness of clinical supervision for a group of wardmanagers based in a district general hospital: an evaluative study

CYNTHIA DAVIS R G N , B S c ( H o n s ) H e a l t h c a r e P r a c t i c e1 and LINDA BURKE P h D , M A , R G N , B A ( H o n s )

2

1Deputy Director of Nursing, Mayday Healthcare NHS Trust and 2Honorary Fellow, Faculty of Health and SocialCare Sciences, Kingston University and St George�s University of London, London, UK

Introduction

The introduction of clinical supervision to support

nurses and their professional development is crucial in

enabling nurses to review their practice and ensure that

care is effective and evidence based (Bishop 2001). The

value of clinical supervision has been examined in the

literature (Spence et al. 2002, Howatson-Jones 2003).

The expectation is that accountable, autonomous

practitioners reflect on their practice to enhance their

skills (Department of Health [DoH] 1998, 1999).

The current study presents the results of an evaluative

audit of the implementation of clinical supervision in

one NHS Trust from a UK perspective. This is impor-

tant for managers because there is little empirical

research that addresses the implementation of clinical

Correspondence

Linda Burke

Faculty of Health and Social Care

Sciences Kingston University and

St Georges University of London

Kingston Hill Kingston, KT27LD

UK

E-mail: [email protected]

D A V I S C . & B U R K E L . (2011) Journal of Nursing Management

The effectiveness of clinical supervision for a group of ward managers based ina district general hospital: an evaluative study

Aim To present an evaluative audit assessing the effectiveness of clinical supervisionfor ward managers.

Background A year-long project to introduce clinical supervision to ward managers

was implemented and evaluated. The objectives were to evaluate staff perceptions of

implementing clinical supervision and determine its outcomes.

Method An audit evaluation process was used.Results Findings are presented against perceptions, implementation and reported

outcomes of clinical supervision. Insights were gained into its relevance and

importance to nurses and the organization. Findings show that clinical supervision

was perceived to be effective and helped improve patient care, but some feared it

becoming a form of managerial control.

Conclusions Ward managers perceived advantages for personal and professional

development from adopting this process.

Implications for Nursing Management There is a need for greater understanding of

clinical supervision before Trusts implement it. The introduction of a resource pack

for clinical areas would also be of value. Finally, there needs to be a named person

who has a special knowledge of clinical supervision to act as a champion and change

agent in effecting implementation at both the executive level and within each

clinical area.

Keywords: change management, clinical supervision, lifelong learning, personal and

professional development

Accepted for publication: 16 May 2011

Journal of Nursing Management, 2011

DOI: 10.1111/j.1365-2834.2011.01277.xª 2011 Blackwell Publishing Ltd 1

supervision from the managers� perspective. The find-

ings from the present study offer valuable lessons for

Trusts aiming to implement clinical supervision in order

to avoid the potential pitfalls.

The present study is of particular use to ward man-

agers at this time because with the impact on healthcare

of the economy and an all degree profession, organi-

zations need to strengthen review processes which

support professional development in a cost-effective

way – which this study proposes. The learning from

the study about the provision of clinical supervision

may be transferable to other similar Trusts or teaching

hospitals.

Background and context

The Trust believed that clinical supervision should

provide a forum where practitioners feel safe to exam-

ine their practice, plan actions for improvement and

raise staff morale. It was therefore decided to introduce

supervision across the Trust, in the first instance for

Ward Managers, in 2004. The introduction included

training sessions for both supervisors and supervisees.

The supervisors received 2 days training, whereas the

supervisees were given 1 day. The intention was to have

planned sessions for 6 months and evaluate this before

delivery to other grades of nurses. An evaluative audit

took place a year after implementation. The Trust was

based in the South East of England and, at this time,

had approximately 600 beds and covered a range of

specialities including acute services, paediatric, critical

care and maternity care.

The rationale for conducting this audit was threefold.

First, clinical supervision is expected by the Nursing

and Midwifery Council (NMC) (2001) of all practitio-

ners. Second, evaluation has been recommended by the

National Institute for Clinical Excellence (NICE)

(2002) as a measure of good practice against expected

levels of performance. Furthermore, it was hoped that

knowledge gained from the audit would lead to

improvements for the group of managers and inform a

roll-out programme of clinical supervision to all nurses

within the Trust. Finally, implementation would facili-

tate the meeting of an objective within the Clinical

Governance agenda (Cranston 2002), which holds

healthcare organizations responsible to ensure clinicians

have access to support and supervision in the exercise of

their responsibilities.

The audit took place at a time where there were many

changes within the organization including the appoint-

ment of a new Director of Nursing and Chief Executive,

and the introduction of targets within Accident and

Emergency. The group reported that having the

opportunity to discuss work and the pressures relating

to them would enable them to reflect on actions and

better manage their areas of responsibility, patient care

and staff using colleague support.

Literature review

Definitions of clinical supervision

Much of the literature relating to clinical supervision

focuses on the problem of definitions (Bush 2005).

Clinical supervision is a practice that originates from

psychotherapy as an essential element of practice. Ber-

nard and Goodyear (2004) define clinical supervision

as:

�This relationship is evaluative, extends over time

and has the simultaneous purposes of enhancing

the professional functioning of the more junior

person and monitoring the quality of the profes-

sional services� (Bernard & Goodyear 2004, p. 8).

The UKCC (1996) added reflection as an integral

component of clinical supervision, suggesting that

clinical supervision is a practice-focused relationship

that involves a practitioner reflecting on practice, gui-

ded by a supervisor. Bishop (2001) suggests that it is a

planned formal, confidential discussion, in a safe envi-

ronment, with one or more individuals, to assist prac-

titioners to develop skills, knowledge and professional

values throughout their careers.

However, although these definitions offer different

insights into the nature and purpose of clinical

supervision, they also reveal the variations (Lyth 2000,

Bishop 2001, Howatson-Jones 2003). Bush (2005)

suggests that there are problems for nurses that are

inherent in the use of the word �supervision� which

conjures up images of surveillance by the organization.

The UKCC (1996), however, argues that clinical

supervision is not a managerial control system, or

hierarchical.

Milne (2007) found that the most widely accepted

definition of clinical supervision was that of Bernard and

Goodyear (2004) but that this definition is not specific

enough and proposed a more empirical definition:

�A formal process by senior/qualified health prac-

titioners … which supports, directs and guides the

work of colleagues (supervisees) (Milne 2007,

p. 440)�.

More recently, White and Roche (2006) have defined

clinical supervision as:

C. Davis and L. Burke

2 ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management

�...participants have an opportunity to evaluate,

reflect and develop their own clinical practice and

provide a support system for one another� (White

& Roche 2006, p. 214).

In some respects, this definition combines the best of

all previous definitions by the creation of an environ-

ment for clinical supervision and using a process of

evaluation and reflection to both develop clinical prac-

tice and provide mutual support. This definition also

implies a peer-to-peer approach to clinical supervision

rather than one with a strong element of authority.

Staff perceptions of clinical supervision

Butterworth et al. (1997) found that practitioners held

a variety of beliefs about clinical supervision, from

realizing that it was more than support but encourages

safe practice, quality control and accountability. How-

ever, Cole (2002) believes nurses have concerns around

the realities of time, workload and whether supervision

has a managerial agenda.

Begat et al. (1997) concluded that affirmation is an

important ingredient in clinical supervision and is

essential for job satisfaction, personal development and

to provide quality care. They found that nurses who

engage in clinical supervision report positive influences

on self-awareness, self-value and an improvement in

communication. Help in coping with difficult events is

also reported by Teasdale (2001).

The literature also mentions barriers to implementa-

tion (Johns 2001, Howatson-Jones 2003, Bush 2005).

Bush (2005) identifies some of these as:

• who carries out supervision and choice of supervisor;

• lack of desire to expose personal feelings to another;

• feelings of loss of autonomy;

• tendency to equate clinical supervision with perfor-

mance review; and

• supervision being imposed on clinical staff.

McSherry et al. (2002) argue that the challenge of

implementing clinical supervision lies in breaking down

barriers within the organization and the ability of senior

managers to �sell� the idea to all staff. There might be a

need, therefore, for the involvement of managers in

providing resources and a coordinated approach

(UKCC 1996).

The benefits of clinical supervision

Begat and Severinsson (2006) explored the question:

How does clinical supervision enhance nurses� experi-

ences of well being in relation to their psychosocial

work environment? They found that it helps nurses

experience feelings of well-being in relation to their

working environment which enables nurses to develop a

strong realization of the significance of caring and

nursing. The reflective processes used in clinical super-

vision enable nurses to be clearer about their purpose.

Cutcliffe and Hyrkas (2006) studied a sample of 74

health care professionals from eight different disciplines

to determine multi-disciplinary attitudes towards clini-

cal supervision. A total of 17 statements about clinical

supervision were used in the previous study. Findings

showed that one item – confidentiality – scored the

highest across all the disciplines in terms of importance

as a characteristic of the clinical supervisor. The least

important characteristic was seen as the need for the

clinical supervisor to be a manager. This demonstrates

that the clinical supervision relationship is separate to

the managerial relationship and that maintenance of

confidentiality is of paramount importance.

Clinical supervision and clinical leadership

Clinical supervision can play a role in creating trans-

formational leaders (DoH 1999). Johns (2003) under-

took a study to evaluate the effect of clinical supervision

on leadership. He found that ward managers lacked

vision and expressed difficulty in maintaining clinical

credibility. Difficulty in facilitating their staff into

accepting role responsibility was expressed. Innovations

were not introduced or implemented for fear of conflict

and there was a culture of conflict avoidance. Clinical

supervision proved to have limited effect in developing

transformational leaders for which Johns (2003) lists a

number of factors including an unsympathetic organi-

zational culture. Ward managers brought mainly neg-

ative events to clinical supervision sessions, echoing

early work of Maggs and Biley (2000) who report that

nurses find it easier to highlight things that went badly

and harder to identify those that go well.

Alleyne and Jumaa (2007) provided an innovative

approach to implementing clinical supervision that used

management and leadership tools to overcome resis-

tance to the implementation. Use of such leadership

interventions significantly influenced nurses� capacity to

improve care and increased their confidence. As a result

of the leadership techniques used as part of group

clinical supervision, the nurses involved developed

their own leadership skills. Sirola-Karvinen and Hyrkas

(2008) explored the benefits of supervision for

nurse managers in several specialities using a clinical

Effectiveness of clinical supervision

ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management 3

supervision evaluation scale. Their findings showed that

supervision for nurse managers was successful,

although there were significant differences between

managers in different specialities and lengths of expe-

rience. Managers in the mental health sector appeared

to use clinical supervision most effectively and manag-

ers who had the greatest length of service experience

perceived supervision as being most valuable. Similarly,

Hyrkas et al. (2005) explored the benefits of clinical

supervision for nurse managers. They found that the

nurse managers reported positive long-term effects on

their leadership and communication skills, the desire for

self-development, their self-knowledge and their ability

to cope with the demands of their managerial role. They

perceived that clinical supervision would provide them

with a broader understanding of their work.

One-to-one vs. group clinical supervision

Commenting on one-to-one sessions, Sloan (2001)

found that the supervisee can restrict the extent of their

development by censoring what is disclosed. McSherry

et al. (2002) maintain that the disadvantages of one-to-

one clinical supervision are that it promotes introverted

thinking. Jones (1999) suggests that working in small

groups is a more effective method for identifying

strengths and creating supportive networks. Several

studies have examined the positive effects of group

clinical supervision (Hyrkas & Lehti 2003, Cutcliffe &

Hyrkas 2006, Alleyne & Jumaa 2007). Alleyne and

Jumaa (2007) went beyond the exploration of the ef-

fects of group clinical supervision to include the impact

of a particular process – the Clinical Nursing Leader-

ship Learning and Action Process (CLINLAP) – which

highlighted the range of facilitative skills that are

needed when implementing a group approach to clinical

supervision.

However, a study into team clinical supervision

undertaken by Hyrkas and Appleqvist-Schmidlechner

(2003) demonstrated that group clinical supervision is a

challenge for supervisors. The study showed that group

supervision did not foster feelings of togetherness

within the team. As a result of the group clinical

supervision sessions teams were engaging in more joint

decision-making, however, conflicts amongst team

members were also reported. Although communication

was found to have become more open amongst team

members, honesty varied between teams. This led to

increased tensions in some teams.

In summary, the literature review has shown that

definitions of clinical supervision vary extensively. A

number of benefits of clinical supervision are high-

lighted in the literature including management of stress

and ability to cope with stress, increased confidence and

development of leadership and communication skills.

One-to-one and group clinical supervision have been

explored in the literature and group supervision appears

to be favourably perceived, in spite of presenting dif-

ferent challenges for supervisors. Although several

studies in the literature related to supervision for nurse

managers, these appear to largely focus on using

supervision to develop leadership skills. There is little in

the literature that explores nurse managers� perceptions

of how clinical supervision helps them in their clinical

role.

The evaluation audit methodology

Rationale for methodology

An audit is a methodical and systematic review of

practice (Parsley and Corrigan, 1999).

Clinical Supervision was re-introduced throughout

the Trust as a planned approach in making it available

to all registered nurses in 2004. It had previously been

introduced but encountered well-documented issues

with sustainability. With this second roll-out, starting

with ward managers, it was agreed to monitor uptake

as part of the Trust quality monitoring audit plan. A

draft proposal for the study was presented to the Trust

and advice was received that, in view of this audit being

within the on-going Trust audit plan, formal ethical

approval was unnecessary. The audit was carried out

with the full agreement of the Director of Nursing, the

Senior Nurse Managers, Ward Managers and a Clinical

Auditor. The audit was conducted as part of the Trust

annual programme.

As the researcher was a line manager to many of the

participants it was important to ensure participant

anonymity to enable them to provide a true reflection of

their views. The researcher discussed the audit verbally

with participants at a briefing meeting and addressed

any concerns. They were also reassured that they did

not have to participate. In addition, a letter was sent

requesting their participation and assuring confidenti-

ality. In terms of anonymity, confidentiality, well-being

of participants, risks and benefits of the study – these

were discussed verbally at the briefing in addition to

points included in the briefing letter. The Clinical Audit

Manager (not the researcher) received all completed

questionnaires to secure anonymity and confidentiality.

The purpose of the audit was to evaluate the clinical

supervision activity of a group of ward managers with a

twofold intention of:



• implementing change to improve the ward man-

ager�s clinical supervision process, with a view to

implementing the process for the other grades of

nurses; and

• establishing whether the guidelines for clinical

supervision required revision.

The evaluation would give practitioners an opportu-

nity to obtain feedback on what they were doing in

practice. Through the implementation of a subsequent

action plan, change would bring about practice devel-

opment.

Sample and data collection

A purposive sample of 24 ward managers in the three

divisions of a large district general hospital was selected

based on their experience of clinical supervision.

Data were collected a year after the start of

monthly clinical supervision with the group of ward

managers in 2004. The data collection tool included

three separate questionnaires which were based on an

existing, validated questionnaire from a larger study

previously carried out by J. Ward and J. Tapping

(unpublished data) which was used with permission.

This was based on the literature along with a number

of exploratory interviews with staff involved in clini-

cal supervision. The questions had then been tested on

further staff including supervisees, supervisors and

facilitators.

However, rather than administering it as one tool, it

was broken down into three sections and administered

separately. The questionnaire used had already been

tested and validated, it was therefore not felt the much

would be gained from further pilot testing. Briefings

were given verbally in addition to written information

of the administration of each tool.

They were administered as follows:

• A 57-item questionnaire was sent by post to all 24

ward managers. This questionnaire focused on defi-

nitions of clinical supervision, the process and nurses�experiences of clinical supervision.

• An additional 11-item questionnaire was collectively

administered at a Ward Managers Development

Day where time was allocated on the day to com-

plete the questionnaire (see Appendix 1). This elic-

ited participants� reasons for starting clinical

supervision, the benefits and negative aspects. All 24

ward managers were present. Collective adminis-

tration is described as one of the best ways of

ensuring a high response rate (Polit & Hungler

1999).

• A six-item questionnaire was administered that

looked specifically at training and was collectively

administered with a sub-sample of nine medical ward

managers.

All questionnaires consisted of Likert-type questions

with some opportunity for open-ended responses. The

scale used was:

1 = strongly disagree

2 = disagree

3 = don�t know

4 = agree

5 = strongly agree.

Data analysis

Data analysis was undertaken using the Statistical

Package for Social Services S P S S (http://www-01.ibm.

com/software/analytics/spss/) for Windows, version

11.0. As there were three separate questionnaires, access

databases were used for each questionnaire. The analysis

was descriptive using percentages and frequency dis-

tribution. Qualitative data were analysed by themes.

The response rate from the questionnaire posted to 24

Ward Managers showed that 13 completed forms were

received (54%); from the questionnaire collectively

administered a month later with the same 24 Ward

Managers, 20 were returned (83%) and there was a

return of seven from the nine ward managers (78%) to

whom the training questionnaire was administered.

Findings

In terms of demographic data, length of time in the role

was sought (Figure 1). Fifty per cent of respondents

indicated that they had been receiving clinical supervi-

sion for over a year.

Length of time in current jobOver 5 years4–5 years2–3 years0–1 years

No

of re

spon

dent

s

7

6

5

4

3

2

1

0

Figure 1Length of time in current post.



Definitions of clinical supervision

Clinical supervision was variously defined by ward

managers. The definitions included having the opportu-

nity to share ideas, express concerns, problem solve and

develop professional skills in patient care. Confidential-

ity and meeting outside the clinical situation in a relaxing

atmosphere were identified as significant aspects. Both

one-to-one and group supervision were described as

modes of delivery and three respondents mentioned the

importance of reflection. The definitions of clinical

supervision from the ward managers compared well to

that in the Trust guidelines for clinical supervision

(which adopts the definition of Butterworth & Faugier

1992). In addition, the objectives of supervision identi-

fied by the ward managers closely reflected the stated

objectives for clinical supervision in the Trust guidelines.

Attitudes to clinical supervision

Only seven out of 13 responded to the question about

whether clinical supervision was a passing fad, four of

whom disagreed or strongly disagreed and three who

were unsure. Over 30% indicated they perceived clini-

cal supervision to be a form of management control.

Hopes and fears of clinical supervision

Before starting, 55% of respondents were doubtful that

it could help them and correspondingly, 61% were

dubious about the real benefits to be gained from it.

However, 80% expected clinical supervision to help in

maintaining high standards of work, and 82% expected

it to help their professional development (see Figure 2).

Implementation of clinical supervision

Reasons for starting clinical supervision

Learning from their experiences and improvements to

patient care were the main motivators for starting

clinical supervision. No one gave �recommendation by

professional body� as their rationale.

Receiving clinical supervision

Of the 13 ward managers who responded to the initial

postal questionnaire, 10 had received clinical supervi-

sion, with one of that number not currently receiving it.

The reason for discontinuing was not revealed. Of the

three who did not receive clinical supervision, the rea-

sons given were that they did not know about clinical

supervision, could not find a group to join, did not have

a supervisor or workload was too demanding.

Involvement in clinical supervision sessions

Managerial instigation was the most frequently re-

ported way in which respondents became involved in

clinical supervision. This is unsurprising as the imple-

mentation was motivated both by the targets set for the

nurse managers and their desire to establish clinical

supervision as a part of everyday practice. However,

0

10

20

30

40

50

60

70

80

90

% re

spon

se

Didn’t really know it

could help

Help maintain

high standards of work

Management checking up

on us

Dubious about the

real

Expected it to help

professional development

Worried about

losing some autonomy

Gain more support

and reduce

Disagree Don't know Agree

Figure 2Perceptions of clinical supervision mentioned by participants about clinical supervision before starting the programme.



over 25% of respondents indicated that it was their own

choice to be involved in clinical supervision.

Method of clinical supervision, timing and number of

sessions attended

The ward managers met mainly in uni-disciplinary

groups. In addition to monthly clinical supervision

groups, it was expected that practitioners have a one-to-

one session at least twice per year. From the question-

naires, it appears that clinical supervision sessions lasted

between 1 and 2 hours, every 4–6 weeks. Satisfaction

was expressed with both length of time and frequency.

Of the 10 respondents who answered the question

about number of sessions attended, six attended be-

tween four and seven supervision sessions in the year,

two respondents attended two sessions and two further

respondents attended more that seven sessions in the

year. Those identifying reasons for non-attendance cited

annual leave, sickness, work pressures, childcare prob-

lems and poor implementation. Time pressures were the

most frequently mentioned. The 10 who responded

to this question, however, stated their intention to

continue.

Choice of supervisor and training

Of the 10 who responded to the question regarding

choice of supervisor, seven reported that they had

chosen their own. Although more issues were solved

through group discussion than through the supervisor�sadvice, the supervisor was seen as crucial to the group

and confidence was expressed with the style of facili-

tation. However, the development of supervision skills

was identified as a problem for 25% of supervisors. Six

stated they had undertaken a 2-day supervisors� training

programme, one had attended a half-day training event

and, in addition, two had completed the CPD module in

Teaching and Assessing.

Reported outcomes of clinical supervision

Benefits to practitioners

Ward managers felt they had achieved better commu-

nication with colleagues, had become more reflective

about their practice and were helped to maintain pro-

fessional standards by encouragement to consider issues

around professional development. Other benefits were

around working relationships, for example, sharing

ideas and experience and improved problem-solving

skills. A summary of the identified benefits to practi-

tioners can be found in Figure 3. Findings showed that

60% felt that clinical supervision had helped them to be

more motivated and 57% felt they were more confident.

These compare favourably with the Trust�s stated

objectives for clinical supervision.

Clinical supervision appeared to make ward manag-

ers feel supported and less stressed. They indicated that

they believed clinical supervision should be available to

all nurses.

Benefits to the organization and to patient care

Notable perceived benefits to the organization reported

by 70% of respondents were that they helped to meet

the requirement of clinical governance. In addition,

78% perceived that clinical supervision assisted in

addressing issues related to policy and procedure. Ward

managers also perceived that they received help to cope

with changes taken place in the Trust.

Perceived benefits to patient care in the promotion of

evidence-based practice and improved problem solving

were identified from the data. However, along with

clinical supervision, other innovations in patient care

improvements were being introduced at the same time

as this evaluative audit was undertaken so it is impos-

sible to claim a causal relationship between clinical

supervision and improvements in patient care.

Negative outcomes

Ward managers in the present study were open about

negative aspects of clinical supervision. Negative com-

ments included time constraints, fears of a breech in

confidentiality and anxiety about experiencing uncom-

fortable feelings such as embarrassment, fear of expo-

sure, intimidation and inadequacy.

0

5

10

15

20

25

30

3535

25

20 20

15

20

10

20

30

% re

spon

dent

s

Perceived benefits

Figure 3The benefits of clinical supervision identified by Ward Managers.



Discussion

The findings of the evaluation indicated that, on the

whole, there was compliance with the Trust clinical

supervision guidelines by the ward managers. However,

it was also apparent that there were aspects of the Trust

guidelines that did not reflect recommendations in the

literature.

Although ward managers held high expectations of the

benefits of clinical supervision, they remained suspicious

of its intent (Heath 2000). They were concerned that the

process was a passing fad, a form of managerial control

and some feared loss of autonomy. These perceptions

echo the literature related to resistance to change and

barriers to effective implementation (Johns 2001,

Howatson-Jones 2003). More than a year after imple-

mentation, fears regarding clinical supervision being a

managerial tool had only marginally improved. Some

researchers argue for a need to ensure that clinical and

managerial supervision are entirely separate. However,

others, such as Gray (2001), welcome the use of a com-

bination of managerial and clinical supervision as the

way to forward the clinical governance agenda. To

encourage adoption of the change, effective leadership is

seen as essential (Nemeth 2003). The ward managers

demonstrated positive movement, from awareness and

expressions of interest when the innovation was first

proposed, to trying out and evaluating clinical supervi-

sion, with the majority stating the intention to continue.

Adoption of the change, therefore, had started to occur.

Interestingly, no staff held the view that �we do it

already� as demonstrated by Butterworth et al. (1997).

Rather, the need to learn more about clinical supervi-

sion was expressed.

The many definitions of clinical supervision given in

the present study reflect the literature (Butterworth &

Faugier 1992, DoH, 1993, UKCC 1996, Bush 2005).

Ward managers� reasons for starting clinical supervision

showed that they had taken personal responsibility for

the process. This corroborates with the adoption of

innovation theory for bringing about planned change

(Sanson-Fisher 2004, White 2004). In addition to this,

an identified person committed to making it happen was

leading the implementation. From the literature this is

an important element to ensure effective implementa-

tion (Devine & Baxter 1995).

Among the ward managers, group supervision was

the main method used. In addition, Trust guidelines

stipulated two-one-to-one sessions annually. Not only

is this prescriptive but also overlooks preferences and

conflicts with literature emphasizing the importance of

the development of a model which meets local need

(Sloan 2001, Johns 2003,). In practice, it was found

that individuals had one-to-one sessions on an infor-

mal basis when felt necessary, supporting Teasdale

(2001).

Making time for clinical supervision was expressed as

a negative aspect as a result of workload constraints and

the process itself being time consuming. This correlates

with similar discoveries by Johns (2003). Taking time

out from work to attend is also identified as an area

where practitioners express feelings of guilt at leaving

patients and their colleagues.

Most of the ward managers choose their own group

supervisor (UKCC 1996, Johns 2001, Sloan 2001),

whose characteristics were seen as crucial in enabling the

process. The selection of the right person as a supervisor

(Heath 2000, Freshwater 2001) and the provision of

training in developing an understanding of clinical

supervision and its intent are crucial starting points

(Johns 2001, Sloan 2001). Other relevant factors are the

need for supervisors to receive supervision themselves

(Fowler 1996) and for implementation to commence as a

bottom-up process, meeting the needs of junior staff first

(Teasdale 2001).

The report of positive outcomes is important both to

the individuals and the organization (Gray 2001).

Becoming more reflective about practice had been sup-

ported by having the time and space to stand back from

situations to encourage learning through experience.

Ward managers reports of developing a better under-

standing of clinical supervision, learning from each

other by sharing experiences and receiving mutual

support are corroborated in the literature. Bishop

(2001) argues that professional development is not an

activity which can be achieved in isolation but is a dy-

namic process requiring peer support and peer review.

The ward managers� peer group supervision enabled

that process. They also felt clinical supervision had

helped them to become more motivated. This echoes a

finding of Begat et al. (1997).

Negative outcomes, suspicion and resistance are

among the issues commonly identified as barriers to

involvement in or implementation of clinical supervi-

sion. The findings in the current study presented here

reflect this. Developing an effective implementation

strategy involving key people at all levels in the orga-

nization, including champions interested in clinical

supervision and committed to making it happen, is

essential to successfully embedding it into practice

(Nemeth 2003).

Improvements in patient care as a result of clinical

supervision have been difficult to demonstrate (Teasdale

2001), however, the ward managers in this evaluative



audit reported perceptions of improved patient care and

professional development.

There are limitations to the present study. First, an

audit takes only a snapshot view at a fixed point and

may not be reflective of trends over time. As practitio-

ners themselves are involved in the process, the rigour

of the study may be affected by the Hawthorne effect

(Doordan 1998) where the subject�s awareness of taking

part in a study alters their response. Second, this was a

small local evaluative audit and the results, therefore,

cannot be generalized to other locations (although there

are clearly lessons that can be learned). Third, there is

an argument that the purposive sample chosen for this

audit might potentially lead to bias on the part of the

lead auditor.

Implications for nursing management

Several recommendations for nursing management in

the Trust have emerged from this evaluative audit of the

implementation of clinical supervision. First, the Trust

acknowledges that there is a need for a more coordi-

nated definition of clinical supervision and a greater

understanding of different models of supervision. This

could be addressed as parts of a resource pack for each

clinical area that includes recent research studies and

articles, Trust guidelines, names of local facilitators,

one-to-one or group models and modes of clinical

supervision. Additionally, as a Trust, it was decided to

review the Trust clinical supervision guidelines to en-

sure that these accurately reflect the evidence base from

the literature. The Trust also recognizes the need for a

named person at an executive level to champion clinical

supervision strategically, and an identified lead or

champion in each clinical area, who has a special

interest in and knowledge of clinical supervision, and

who will act as change agent in effecting implementa-

tion. Finally, as a result of this audit and the imple-

mentation of clinical supervision with this level of ward

manager, the Trust has since embarked on an extensive

2 year in-house continuing professional development

programme to develop the wider leadership potential of

this group of ward managers.

Conclusions

In spite of their reservations about some aspects of

clinical supervision, ward managers perceived that there

were advantages in personal and professional develop-

ment from adopting this process. However, in spite of

their positive experiences, the possibility of clinical

supervision being used as a management tool still per-

sists. Ward managers valued choosing their supervisor,

the provision of training to help develop the skills

needed to facilitate a group and having the opportunity

to explore practice in a safe supportive environment. If

clinical supervision becomes accessible to all practitio-

ners, the necessary framework, including the allocation

of time, training and personnel, needs to be established.

The findings of the evaluation show that clinical

supervision activity for this group of ward managers

has been effective, as demonstrated by their reported

benefits, and by comparisons against both the Trust

guidelines and the literature. Although the findings

reveal some areas where change is needed, a large

degree of compliance was found. The study is particu-

larly useful, as auditing of clinical supervision for this

group of nurses is not commonly found. The learning

from the study may therefore be transferable to similar

Trusts or larger teaching hospitals. In addition, rec-

ommendations from this study suggest exploration of

other types of supervision including for multidisciplin-

ary groups or community/acute staff could be useful.

Working in an NHS environment where both change

and increasing expectations of practitioners are con-

stant features, investing in clinical supervision has the

potential to develop supportive networks for individu-

als and teams, and to engender lifelong learning and

improve professional development.

Source of funding

None.

Ethical approval

As Part of the trust audit process formal approval was

not necessary although order of nursing approval was

gained.

References

Alleyne J. & Jumaa M. (2007) Building the capacity for

evidence-based clinical nursing leadership: the role of execu-

tive co-coaching and group clinical supervision for quality

patient services. Journal of Nursing Management 15 (2),

230–243.

Begat I. & Severinsson E. (2006) Reflection on how clinical

nursing supervision enhances nurses� experiences of well-being

related to their psychosocial working environment. Journal of

Nursing Management 14 (8), 610–616.

Begat I., Severinsson E. & Berggern I. (1997) Implementing of

clinical supervision in a medical department: nurse�s views of

the effects. Journal of Clinical Nursing 6, 389–394.

Bernard J.M. & Goodyear R.K. (2004) Fundamentals of Clinical

Supervision. Pearson, Boston, MA.



Bishop V. (2001) Professional development and clinical supervi-

sion. In Challenges in Clinical Practice (V. Bishop & I. Scott

eds), pp. 76–94. Palgrave, London.

Bush T. (2005) Overcoming the barriers to effective clinical

supervision. Nursing Times 101 (2), 38.

Butterworth T. & Faugier J. (1992) Clinical Supervision and

Mentorship in Nursing. Chapman and Hall, London.

Butterworth T., Carson J., White E., Jeacock J. & Bishop V.

(1997) It�s Good to Talk. University of Manchester, Man-

chester.

Cole A. (2002) Someone to watch over you. Nursing Times

98 (23), 22–24.

Cranston M. (2002) Clinical effectiveness and evidence-based

practice. Nursing Standard 16 (24), 39–43.

Cutcliffe J. & Hyrkas K. (2006) Multidisciplinary

attitudinal positions regarding clinical supervision: a cross

sectional study. Journal of Nursing Management 14 (8),

617–627.

Department of Health (1993) A vision for the future: The nursing,

Midwifery and Health Visiting Contribution to Health and

Health Care. The Stationary Office, London.

Department of Health (1998) A First Class Service: Quality in the

NHS. The Stationary Office, London.

Department of Health (1999) Making a Difference: Strength-

ening the Nursing, Midwifery and Health Visiting Contri-

bution to Health and Health Care. The Stationary Office,

London.

Devine A. & Baxter T. (1995) Introducing clinical supervision a

guide. Nursing Standard 40 (9), 32–34.

Doordan A. (1998) Research Survival Guide. Lippincott, Phila-

delphia, PA.

Fowler J. (1996) The organisation of clinical supervision with in

the nursing profession: a literature review. Journal of Advanced

Nursing 23 (3), 471–478.

Freshwater D. (2001) Prison health care: developing leadership

through clinical supervision. Nursing Management 8 (8),

10–13.

Gray W. (2001) Clinical Governance combining clinical

and management supervision. Nursing Management 8 (6),

14–22.

Heath H. (2000) Clinical supervision as an emancipatory process:

avoiding inappropriate intent. Journal of Advanced Nursing

32 (5), 1298–1306.

Howatson-Jones I. (2003) Difficulties in clinical supervision and

lifelong learning. Nursing Standard 7 (37), 37–41.

Hyrkas K. & Appleqvist-Schmidlechner K. (2003) Team super-

vision in multi-professional teams: team members� descriptions

of the effects as highlighted by group interviews. Journal of

Clinical Nursing 12 (2), 188–197.

Hyrkas K. & Lehti K. (2003) Continuous quality improvement

through team supervision supported by self-assessment and

systematic patient feedback. Journal of Nursing Management

11 (3), 177–188.

Hyrkas K., Appleqvist-Schmidlechner K. & Kivimaki K. (2005)

First-line managers� views of the long-term effects of clinical

supervision: how does clinical supervision support and develop

leadership in health care? Journal of Nursing Management

13 (3), 209–220.

Johns C. (2001) Depending on the intent and emphasis of the

supervisor, clinical supervision can be a different experience.

Journal of Nursing Management 9 (3), 139–145.

Johns C. (2003) Clinical supervision as a model for clinical

leadership. Journal of Nursing Management 11 (1), 25–34.

Jones A. (1999) Clinical supervision for professional practice.

Nursing Standard 14 (9), 42–44.

Lyth G. (2000) Clinical supervision: a concept analysis. Journal of

Advanced Nursing 31 (3), 722–729.

Maggs C. & Biley A. (2000) Reflections on the role of the nursing

development facilitator in clinical supervision and reflective

practice. International Journal of Nursing Practice 6 (4),

192–195.

McSherry R., Kell J. & Pearce P. (2002) Clinical supervision and

clinical governance. Nursing Times 98 (23), 30–32.

Milne D. (2007) An empirical definition of clinical supervision.

British Journal of Clinical Psychology 46, 437–447.

National Institute for Clinical Excellence (2002) Principles For

Best Practice in Clinical Audit. Radcliffe Medical Press,

Oxford.

Nemeth L. (2003) Implementing change for effective outcomes.

Outcomes Management 7 (3), 134–139.

Nursing and Midwifery Council (2001) Clinical Supervision.

NMC, London.

Parsley K. & Corrigan P. (1999) Quality Improvement in

Healthcare. Putting Evidence into Practice, 2nd edn. Stanley

Thornes Ltd, Gloucester.

Polit D. & Hungler B. (1999) Nursing Research. Principles and

Methods. Lippincott, Philadelphia, PA.

Sanson-Fisher R.W. (2004) Diffusion of innovation theory for

clinical change. Medical Journal of Australia 180 (6 suppl),

S55–S56.

Sirola-Karvinen P. & Hyrkas K. (2008) Administrative clinical

supervision as evaluated by first-line managers in one health

care organization district. Journal of Nursing Management

16 (5), 588–600.

Sloan G. (2001) Illuminative evaluation: evaluating clinical

supervision on its performance rather than the applause. Jour-

nal of Advanced Nursing 35 (5), 664–673.

Spence C., Cantrell J., Christie I. & Samet W. (2002) A collab-

orative approach to the implementation of clinical supervision.

Journal of Nursing Management 10 (2), 65–74.

Teasdale K. (2001) Clinical supervision and support for nurses:

an evaluation study. Journal of Advanced Nursing 33 (2),

216–224.

United Kingdom Central Council (1996) Position Statement on

Clinical Supervision for Nursing and Health Visiting. UKCC,

London.

White A. (2004) Change strategies make for smooth transitions.

Nursing Management 35 (2), 49–52.

White E. & Roche M. (2006) A selective review of mental health

nursing in New South Wales, Australia, in relation to clinical

supervision. International Journal of Mental Health Nursing

15, 209–219.



Ap

pen

dix

1:C

linic

alsu

per

visi

on

qu

esti

on

s–

view

s

We

are

inte

rest

edin

findin

gout

about

how

you

feel

about

clin

ical

super

vis

ion

.Ple

ase

tick

inth

ebox

whic

hbes

tre

flec

tsyour

vie

ws

Str

on

gly

dis

agre

eD

isag

ree

Do

n�t

Kn

ow

Ag

ree

Str

on

gly

agre

e

23.

Clinic

al

super

vis

ion

hel

ps

me

main

tain

my

pro

fess

ional

standard

sh

hh

hh

24.

Clinic

al

super

vis

ion

has

hel

ped

me

toco

mm

unic

ate

wit

hm

yco

llea

gues

at

work

hh

hh

h25.

Oth

erse

ttin

gs

(such

as

hand

over

and

work

feed

back

)m

ake

clin

ical

super

vis

ion

unnec

essa

ryh

hh

hh

26.

Clinic

al

super

vis

ion

has

hel

ped

me

tom

eet

the

requir

emen

tsof

Clinic

al

Gover

nance

hh

hh

h27.

Clinic

al

super

vis

ion

has

hel

ped

pro

mote

evid

ence

base

dpra

ctic

eh

hh

hh

Dis

agre

eD

on�t

Kn

ow

Ag

ree

Str

on

gly

agre

eS

tro

ng

lyd

isag

ree

28.

Clinic

al

super

vis

ion

has

impro

ved

the

quality

of

care

Igiv

eto

pati

ents

hh

hh

h

29.

Clinic

al

super

vis

ion

has

hel

ped

me

cope

wit

hth

ech

anges

that

are

curr

entl

yocc

urr

ing

wit

hin

the

Tru

sth

hh

hh

30.

Clinic

al

super

vis

ion

has

hel

ped

me

tow

ork

more

effe

ctiv

ely

wit

hm

ym

anager

hh

hh

h

31.

My

manager

sand

collea

gues

outs

ide

of

super

vis

ion

do

not

reco

gnis

eth

evalu

eof

super

vis

ion

hh

hh

h

32.

Clinca

lsu

per

vis

ion

enco

ura

ges

me

toth

ink

about

issu

esaro

und

my

pro

fess

ional

dev

elopm

ent

hh

hh

h34.

Clinic

al

super

vis

ion

can

oft

enbec

om

eju

stanoth

erm

oanin

gse

ssio

nh

hh

hh

35.

Clinca

lsu

per

vis

ion

has

enco

ura

ged

me

tobec

om

em

ore

reflec

tive

about

my

pra

ctic

eh

hh

hh

36.

Clinca

lsu

per

vis

ion

has

hel

ped

me

dea

lw

ith

dif

ficu

ltie

sin

rela

tionsh

ips

at

work

hh

hh

h

37.

Clinic

al

super

vis

ion

has

made

me

feel

more

support

edat

work

hh

hh

h38.

Clinic

al

super

vis

ion

has

hel

ped

me

reduce

the

level

of

stre

ssI

exper

ience

at

work

hh

hh

h

39.

Clinic

al

super

vis

ion

has

hel

ped

tom

oti

vate

me

hh

hh

h

40.

Clinic

al

super

vis

ion

isju

stanoth

erfo

rmof

manager

ial

contr

ol

hh

hh

h

41.

Clinic

al

super

vis

ion

has

hel

ped

me

addre

ssis

sues

rela

ted

topolice

s/pro

cedure

sh

hh

hh

42.

Clinca

lsu

per

vis

ion

has

open

edm

yey

esto

som

eof

the

pro

ble

ms

my

collea

gues

exper

ience

hh

hh

h43.

Clinic

al

super

vis

ion

has

giv

enm

em

ore

confiden

ceh

hh

hh

44.

Itr

ust

my

gro

up

tokee

pall

dis

cuss

ions

confiden

tial

hh

hh

h

Dis

agre

eD

on�t

Kn

ow

Ag

ree

Str

on

gly

agre

eS

tro

ng

lyd

isag

ree

45.

Our

super

vis

or

iscr

uci

al

toth

egro

ups

succ

ess

hh

hh

h46.

Inco

nsi

sten

tatt

endance

at

sess

ions

oft

enpre

ven

tsth

efu

llben

efits

of

clin

ical

super

vis

ion

bei

ng

ach

ieved

hh

hh

h

47.

Ife

elco

mfo

rtab

lebri

ngin

gany

pro

ble

ms

Ihave

tom

ycl

inic

al

super

vis

ion

sess

ion

hh

hh

h48.

More

issu

esare

reso

lved

thro

ugh

gro

up

dis

cuss

ion

than

thro

ugh

the

dir

ect

advic

eof

the

super

vis

or

hh

hh

h

49.

Clinic

al

super

vis

ion

has

hel

ped

me

inw

ork

ing

wit

hpro

fess

ional

from

oth

erdis

ciplines

hh

hh

h

50.

Makin

gti

me

for

clin

ical

super

vis

ion

isver

ydif

ficu

lth

hh

hh

51.

Clinic

al

super

vis

ion

has

enable

dm

eto

dis

cuss

issu

esof

acc

ounta

bilit

yh

hh

hh



Ap

pen

dix

1:(C

on

tin

ued

)

Dis

agre

eD

on�t

Kn

ow

Ag

ree

Str

on

gly

agre

eS

tro

ng

lyd

isag

ree

52

Clinic

al

super

vis

ion

isaim

edat

staff

who

are

havin

gdif

ficu

ltie

sat

work

hh

hh

h53.

Clinic

al

super

vis

ion

isanoth

erpass

ing

fad

hh

hh

h

54.

Clinic

al

super

vis

ion

has

hel

ped

me

dea

lw

ith

pro

ble

ms

rela

ted

topati

ent

care

hh

hh

h

55.

Ilike

my

super

vis

or�

sst

yle

of

faci

lita

tion

hh

hh

h

56.

My

faci

lita

tor

lack

sth

eex

per

tise

inm

yw

ork

are

aof

work

toadvis

em

eon

many

pro

ble

ms

Ibri

ng

hh

hh

h

57.

Clinic

al

super

vis

ion

has

enable

dst

aff

tosh

are

our

anxie

ties

over

the

rece

nt

changes

inth

eT

rust

hh

hh

h

An

yo

ther

com

men

ts:

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------

---------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

TH

AN

KY

OU

FO

RT

AK

ING

TIM

ET

OC

OM

PL

ET

ET

HIS

QU

ES

TIO

NN

AIR

E



The effectiveness of clinical supervision for a group of ward managers based in a district general...

Documents

Transcript of The effectiveness of clinical supervision for a group of ward managers based in a district general...