The concept of professional/clinical supervision arose, and quickly became mandatory within the mental health helping professions of psychology, counselling and psychotherapy. It was then rapidly recognized as effective for clinicians and their patients by nursing and other medical associations and recommended as standard practice within healthcare systems. However, despite clear professional learning and patient benefits, supervisory services and structures within mainstream healthcare systems are often not provided/implemented due to a lack of management commitment and confidence with the professional supervision process. In this paper, we suggest that bringing supervision to the top teams in healthcare will help leaders build confidence with the concept and support them to actively develop their organisations with professional practice and patient benefit in mind.
Birth of Supervision
The requirement for clinical supervision first became apparent within the counselling professions during the 1980’s. Donald Schon (1983) was one of the first to point out that reflective practice, i.e. being able to stand back and take a supported, critical look at your own practice, was the mark of what Robinson (1974) referred to as the “mark of a competent practitioner”. Clinical supervision as a practice then emerged during the early 1990s and Inskipp and Proctor (1993) eventually defined it as ““A working alliance between a supervisor and a counsellor in which the counsellor can offer an account or recording of her work; reflect on it; receive feedback, and where appropriate, guidance. The object of this alliance is to enable the counsellor to gain in ethical competence, confidence and creativity so as to give her best possible service to her clients”. They also put a structure around the supervision process, arguing that it always involves 3 key elements – normative (practice), formative (learning) and restorative (support). Essentially they are describing a partnered and practical learning process, where the learner (supervisee) can feel safe, secure and ably supported to develop at their best. Hawkins & Shohet (1989) developed an umbrella model of the supervision process that sits will as the operation within this definition. They described the supervisor as having 7 eyes, ranging from focus on the client, through the counsellor to the supervisor and all relationships in between, with particular attention also given to detailed interventions and overarching systems within which the work takes place.
Growth in Therapy
This professional practice quickly became very important to the counselling and psychotherapeutic professions as professional leaders came to realise that when operating with mental health issues on a 1-1 basis with clients, therapists had a large degree of opportunity to do non-conscious harm (maleficence) to those clients. The argument was that if the therapists were given the opportunity to stand back, offload their concerns regarding client interactions, and themselves feel safe, secure and supported enough to visit their sub-conscious reactions to their client work, they would then be in a much stronger position to support their own clients.
So supervisory practice grew and became mandatory within psychotherapy, counselling, psychologists and also amongst some groups of allied health professionals, such as speech and language therapists and occupational therapists – all to ensure the support of therapists so that they could continue to deliver the best possible services to their clients.
Not surprisingly, supervision since then has moved more central within the NHS radar. The National Medical Council in 2008 stated that “supervision should be available to registered nurses”, and other professional medical associations made similar statements. Whilst some strides have been made in particular NHS areas to implement good supervisory models, (Waskett, 2009) suggests that the practice of supervision is more of an intention than a reality. He reports that whilst the healthcare system is aware of the need for, and value of supervision, but does not seem to be practising as it has preached, often for seemingly good reasons. Resistance is often around the fact that managers of health professionals are usually not confident about what clinical supervision is, how it should best work, and how a structure for the process can even be put into place. In effect, managers (often non-clinical themselves) are confused and lacking confidence around the implementation of a subject area that they are not, and will probably not, be engaged within.
The Way Forward
However, Waskett (2009) offers a way forward. He suggests a structured process (4S model) to implement a supervision process within any healthcare system –
Structure – define a management stakeholder group who are committed to the process and collaboratively engage on making choices in key areas such as 1-1 or group, optional or mandatory, involvement, timing, resources, logistics & evaluation
Skills – identify natural supervisors within the organisation and ensure they are fully trained, or bring in fully qualified supervisors from outside of the organisation and ensure they engage in a learning process where they develop the internal supervisors
Support – be aware that that supervisors and the healthcare system also need support. Arrange supervision groups for supervisors with fully qualified external professional supervisors, who can also in turn support the emerging organisational developments
Sustainability – create a supervision policy, identify key people responsible for supervision processes & training, secure budgets and resources, and conduct regular evaluations to ensure awareness of benefit to organisation and to clients/patients
This does sound like the streamlined, practical, collaborative and easy to use structure that Waskett was aiming to define, and it undoubtedly offers an approach to implementing professional supervision within a healthcare system – if only the commitment was there!
In the meantime, professional supervision has continued to be further researched within the healthcare system, mainly to identify economic benefits, in addition to professional servicing advances. In 2011, Brink et al applied a group supervision model within the pre-hospital care team (ambulance service) in Sweden and explored its impact on professional and personal development. They found that supervision made it easier for newer members of the team to more rapidly develop expertise in their working area, using the structured group-work input of the more mature members – an important tool in today’s time-pressurised and financially focused environment. They also concluded that the process actively supported participants in developing more competence, compassion, confidence, conscience and commitments in their encounters with patients and colleagues.
With Waskett (2009) having pointed out that management commitment to the concept of supervision is crucial for success of any supervisory system within healthcare, perhaps it may be critical to let them experience the concept for themselves at first hand. Perhaps understandably, their first question will be “What’s the benefit?”. With this question in mind, David & Burke (2012) evaluated the impact of a year-long professional supervision process on a group of nurse managers. They found that the nurse managers’ experience of clinical supervision directly helped to improve patient care, and they offered many examples of impact. In addition, the nurse managers felt that their learning was fully refreshed by the process, that it actively supported their professional development, and made them more accessible, valuable and supportive to their direct reports.
Taking it to the next level
So if nurse managers are finding the process beneficial, the next appropriate step would perhaps be to introduce the concept to the top teams within healthcare systems. This would have three key benefits 1) as management professionals operating with a highly challenging system, supervision would support and equip them with the necessary professional learning to bring the organisation forward, and 2) the use of group supervision would build and strengthen their relationships to the point where they can feel supported and support each other much more strongly in between supervision sessions, therefore given them the strength to support the organisation to the best of their ability, and 3) they would experience the significant developmental benefits of supervision in relation to their management professionalism, and so in turn become more supportive of the use of clinical supervision within the organisation to further support the system of healthcare and directly benefit patients. It’s hard to support any process as a manager if you don’t see or feel the benefit yourself. If managers can fully experience and gain positively from the professional supervisory process, then perhaps they will feel inspired to actively support their clinical teams and their whole organisation to embrace this process, and make the finance available.
Supervising Corporate Systems
Corporates in the areas of Pharmaceuticals, Medical Devices, Insurance Services and Consumer Products are engaging with professional supervision at an organisational level via T-Space. Within the experience of difficult and challenging markets, they are reaping significant benefits directly to the customer interface resulting in competitive advantage in their marketplaces.
The healthcare system is undoubtedly one of the most challenging and difficult service environments in which to operate, both clinically and managerially. Given that professional supervision was originally born of good healthcare intention in the caring professions, perhaps it’s time to go back there, and support the HSE system to refresh itself from the top?
Brink, P., Back-Pettersson, S., Sernert, N. (2011). Group Supervision as a means of development professional competence within pre-hospital care. International Emergency Nursing 20, 76-82.
Davis, C., Burke, L. (2012) The effectiveness of clinical supervision for a group of ward managers based in a district general hospital: an evaluative study. Journal of Nursing Management, 2012 Se; 20(6): 782-93.
Hawkins, P., Shohet, R. (1989) Supervision in the helping professions. Milton Keynes: Open University Press.
Inskipp, F., Proctor, B. (1993) Making the most of supervision. Part 1, Middlesex: Cascade Publications. (2nd Edition, 2001)
Robinson, W.L. (1974) Conscious Competence: the Mark of the Competent Instructor. Personnel Journal, 53, 538-539
Schon, D. (1983) The Reflective Practitioner. New York: Basic Books.
Waskett, C. (2009) An integrated approach to introducing and maintaining supervision – The 4S Model. Nursing Times, 105:17 24-26