Clinical supervision establishes a formal process of support, reflection, learning and development that is of benefit to both newly registered and experienced health professionals by supporting their individual development.
Clinical supervision models
There are multiple different clinical supervision models that can be considered which will be suited to different team dynamics and organisations. We aim to outline some of these models, providing a basis for employers to consider the implementation of a clinical supervision model in their own workplace.
A popular framework that is defined by having three separate areas of supervision. This model is considered the definitive model upon which the below models are based.
- The first area is normative; this focuses on the managerial aspects to learning, which could include core mandatory training and continue professional development.
- The second is formative; this focuses on developing knowledge and skills in professional development and using self-reflection as a tool to further develop self-awareness. This aims to increase the practitioner’s reflection of their own practice.
- The third is restorative; personal development focusing on support, preventing burnout, and learning to better manage stress. This supervision can take place as one-to-one supervision, peer group supervision or a combination of both types.
it is considered to have clearly outlined the different elements that comprise a substantial programme of clinical supervision, as well give them equal weighting to ensure that practitioners consider their own wellbeing as well as personal and professional development. It is also heralded as providing individuals within another avenue for feedback that is beyond the normal managerial feedback process, offering the opportunity for individuals to identify skills to develop or focus on. Whilst offering a solid base to develop clinical supervision models, it does not consider it important to understand why we have an emotional response to a situation, nor identifies service improvement as crucial.
Chapter 3 of Training for the supervision alliance by Brigid Proctor is a crucial text for understanding Proctor’s three-function model.
RBCS is a framework of clinical supervision, developed by the University of Nottingham, that focuses on understanding the emotional systems that prompt a certain response to a situation. It teaches participants how to alleviate this emotional response through understanding and reflecting on why they have responded in a certain way, and in due course to be able regulate this response whilst paying attention to their own wellbeing.
- This framework is useful to the practitioner in a great variety of different situations as it focuses on the root emotional response.
- Creates a safe space for healthcare workers to discuss and explore their feelings, engaging with others but also practicing self-reflection.
- The mindfulness techniques suggested as part of this framework can be used during the working day to refocus and respond positively to difficult situations.
- Recognise situations beyond our control and mitigate the critical self-response.
The Foundation of Nursing Studies offers RBCS resources and course companion guide available for download which provides a good introduction to implementing RBCS in the workplace. For a more in-depth analysis of the benefits of implementing this form of supervision, please refer to this study conducted by the University of Nottingham across six NHS trusts in the East Midlands.
The A-EQUIP Model takes elements of Proctor’s three-function model and develops these further, moving beyond the idea of three functions of supervision by including a further which focuses on personal action and quality improvement. It keeps the restorative elements of Proctor’s model but introduces the concept of using supervision to develop skills to advocate for others, whether this be patients, nurses, or other healthcare staff. By using clinical supervision to teach staff how best to champion the patient view personal care and service delivery are positively affected. This model:
- integrates the patient view as a central part of clinical supervision, positively shaping service delivery and providing the organisation with ongoing feedback on service improvement.
- continues to incorporate the other three elements of Proctor’s model keeping continued professional development, self-reflection, and stress management central to effective supervision.
- encourages innovation, which in turn leads to higher job satisfaction.
- is implemented at the heart of the organisation, through expressly training professional nurse advocates to champion and guide others through the A-EQUIP model.
Introducing A-EQUIP and highlights from a number of A-EQUIP pilot sites is a video providing a good general overview of the model. For those who wish to explore the A-Equip model further, NHS England has a more in-depth document that provides further information.
Birmingham and Solihull Mental Health NHS Foundation Trust implemented drop-in restorative clinical supervision sessions to support staff morale and provide a safe space for staff to communicate. NHS England and NHS Improvement has provided further case studies on the advantages of having a Professional Nurse Advocate within the workplace. We would also recommend reading this overview of the PNA role by The Queen’s Nursing Institute
A tool for structured reflection, Johns (1993) suggests, that when you reflect, you need to make sure that you 'look inwards' (consider your own thoughts and feelings), and 'look outwards' (consider the actual incident or situation, including things like your actions in the situation and whether they were ethical, and the external factors that influenced you).
Nicklin's practice-centred model (1997) of clinical supervision, focuses on the roles and functions of the organisation (managerial, education and support) working together, where a change in one will impact on the others. The model presents supervision as a cyclical process of analysis, problem identification, objective-setting, planning, action and evaluation
Rogers & Topping-Morris problem-focused model (1997) of supervision, was developed in a forensic science unit, wherein supervisor and supervisee identify the clinical problem and use problem-solving strategies to provide a solution that is structured and measurable.
Action learning sets are not intended to be used a supervision model in themselves, but instead to complement and develop clinical supervision by offering the opportunity for individuals to work together to resolve issues that they have identified in the workplace. They provide participants with a forum in which to reflect on their own development, discuss clinical issues, dynamics of the team and support those who are feeling inexperienced or unsupported.
Some of the key benefits of clinical supervision include:
- improved patient care through increased knowledge and skills
- reduction in stress levels and complaints, and an increase in staff morale
- increased confidence and a reduction in burnout and emotional strain
- increased knowledge and awareness of potential solutions to clinical problems
- creation of new nursing roles, such as professional nurse advocates (PNAs) and legacy nurses.
There are some practicalities to consider when implementing clinical supervision, and it is important that the supervisor and supervisee agree:
- the aim of clinical supervision and the process used
- the expectations from the supervisor and supervisee roles.
You will also need to consider how clinical supervision is implemented and delivered:
- face to face/virtual learning
- one to one/group, interprofessional model of learning
- structured framework and documentation
- responsibility of organising meetings (voluntary/optional versus pre-booked/mandatory)
- pre-meeting planning, such as supervisee reflection
- content of supervision, what is appropriate/not appropriate to discuss
- recording the supervision, and responsibility of documentation
- confidentiality, which needs to maintained at all times.
Cornwall Partnership NHS Foundation Trust find action learning sets to be a great complement to their preceptorship programmes, using them at the beginning of every taught session for newly qualified nurses and nursing associates. This takes the form of protected time where those attending are offered the time and space to share issues they might be having with a small group of peers. This time is valuable for seeking reassurance, feedback, and a plan on how to resolve issues moving forward. By placing these sessions at the start of the day attendees can approach the rest of the day with a clean slate, having shared any concerns they are having with the rest of the group.
For the first few sessions the action learning sets are facilitated by coaches from within the organisation, with the intention that beyond the first sessions a coordinator from within the group is chosen for subsequent sessions. The facilitators are, in the majority, trained professionals holding a Level 3 or Level 5 leadership and management qualification or an education qualification (PGCE or equivalent). However, qualifications are not necessary to facilitate the sessions with good interpersonal skills and an ability to encourage participation from a wide range of individuals of equal importance.
The format of the session is conversational and free flowing, issues can be raised by whichever individual would like to begin and develop naturally. Generally, it is found that multiple individuals have similar issues which arises during the conversation, therefore part of the conversation should be how the issues raised resonates with other members of the group. Sometimes issues can be resolved by conversation, and sometimes the group will support in developing an action plan. The group are encouraged to sit in a circle to create equality within the space and everybody is expected to input into the conversation.
The success of these action learning sets has led Cornwall Partnership NHS Foundation Trust to expand their use; they have now been implemented in the induction package for new healthcare support workers six weeks after joining the organisation. It has also been seen as complementary to the CLiP coaching model, allowing mentors and mentees of all different levels to come together to address non-critical issues as a group. Whilst the action learning set style is not suitable for every occasion their successful implementation throughout the trust has served as a great model for the benefits of coaching, and the importance of coaching has been recognised.
Oxleas NHS Foundation Trust has also implemented a six-month action learning programme since 2018 to support the preceptorship of newly-qualified nurses. This decision was taken based on feedback that a dedicated time to share issues with peers was highly valuable. These three-hour long action learning meetings offer groups of five to eight participants the opportunity to ask questions, empower themselves through identifying solutions and support their resilience through sharing coping mechanisms. From 2020, the trust took these meetings were moved to the virtual space based on further feedback received and the trust found that there was no change to the quality of the dialogue, or the benefits gained from action learning sets.