Clinical Supervision: why we need it but need to sort it out.

I passionately believe in the benefits of clinical supervision for nurses from all fields of practice, and I wanted to share my takeaways and opinions regarding clinical supervision and the Royal College of Nursing (RCN) Forums’ “Barriers to overcoming the barriers” scoping review exploring 30 years of clinical supervision literature” published in the Journal of Advanced Nursing.

https://onlinelibrary.wiley.com/doi/10.1111/jan.15283

While there is universal acknowledgement regarding the importance and benefit of clinical supervision for all nurses, especially restorative supervision, there is a lack of clarity regarding how to successfully and meaningfully implement it in practice. Implementing a universal, standardised, formulaic (tick box) approach to clinical supervision will not work and will be counterproductive, especially if, as is the rightful intention, is for all nursing fields to adopt the practice.

In practice, where clinical supervision is provided, there is an increasing occurrence of a hybrid model being adopted, coupling it with line management supervision. These should be distinct, as any amalgamation deviates from the initial intention of clinical supervision. The amalgamation of clinical supervision with line management supervision potentially leads to disengagement, a lack of buy-in and a failure to see the relevance or benefit of clinical supervision in its intended form for those in receipt of it, as it is an alien concept to them.

These negative consequences also apply to facilitators and supervisors. While clinical supervision and nurse line management are both vital to support nurses and for their continuous professional development and, ultimately, patient safety and service delivery, they must remain distinct and be given equal value. However, it is evident due to staffing and time constraints, or a failure to acknowledge the benefit of clinical supervision, that clinical supervision fails to be offered or that sessions are frequently cancelled or amalgamated with other supervision as described. There must be a protected time allowance for clinical supervision.

Additionally, there must be institutional buy-in from organisations who must educate and equip facilitators with the necessary skills to deliver complex clinical supervision both meaningfully and impactfully. Moreover, recognising the benefits clinical supervision has regarding improved patient safety and outcomes in addition to staff support and development, our professional regulator the Nursing and Midwifery Council (NMC) must be more explicit in mandating the need for provision in the NMC Code and all in professional standards for nurses of all fields.

However, the more I reflect, the more I think the term clinical supervision is a barrier itself. The name suggests someone is supervising your “clinical” skills, i.e. line management supervision, or that you are undertaking a supported improvement plan to help support you in practice. The name, clinical supervision, seems divorced from its intent, especially if the call is for us to focus on the more restorative element.

Moreover, clinical supervision, in its essence, should be supportive and autonomously nurse-led, not management driven. Again, this divorces us from its intention. Clinical supervision is meant to help professionals reflect on scenarios that have affected them and support them through these experiences. Whereas in line management supervision, the line manager may identify areas for improvement, is the intent of clinical supervision not to let professionals bring development needs they have autonomously decided they want to work on? Professionals need to feel ownership over this kind of relationship like they are the drivers with a supportive copilot.

Some individuals, in particular, take umbrage with the term supervision. Many people, when they hear the term supervision have connotations of being micromanaged, audited, and being checked “up” on rather than checked “in” on. They can feel as though their professional autonomy is being removed. The term supervision also introduces a sense of hierarchy, much like the terminology change from student mentors to practice supervisors and assessors when the new NMC Standards for student supervision and assessment were implemented in 2019. In healthcare, are we not being encouraged to break down hierarchies, not reinforce them? However, both the change to nursing student support and the inclusion of the term “supervision” in clinical supervision seem counterproductive to achieving that aim.

Whereas clinical supervision is well-established, although still not always provided, in mental health and learning disability nursing, as a registered adult nurse, I genuinely only knew of the practice through my mental health nursing friends. I do not know any registered adult nurses working on wards who receive clinical supervision. I worked in an infectious diseases ward during the start of the Covid-19 pandemic, where it would have been immensely beneficial in preventing burnout and dealing with the enormity of deaths witnessed. But I did not receive any. The first time I received clinical supervision was when I moved into the community and joined a team of registered adult and mental health nurses in an area requiring trauma-informed care.

If the rightful aim is to have clinical supervision be a mandatory, time-protected way of providing professional development and restorative support for nurses of all fields, should inclusive, well-understood terminology not be used? As when describing clinical supervision to registered adult or children and young people’s nurses, they can become defensive, feeling as though their clinical skills are being unfairly critiqued or that they require supervision. Again, the language and terminology are causing a barrier to meaningful and successful engagement, implementation, or, most worryingly, even the desire to receive clinical supervision.

I acknowledge and understand the reluctance to change. Clinical supervision is well embedded in other professional groups with a completely different construct. In those professions, clinical supervision is imperative to ensuring safe, accountable and ethical practice. So, I understand the argument that in rebranding clinical supervision, we risk losing a valuable foundation and evidence base.

However, while I understand the importance of this foundation, I believe for clinical supervision to be inclusively used across all nursing fields that “clinical” makes it sound like it is all about skills and “supervision”, as though those skills need monitoring. It sounds like a management plan and fails to capture the holistic essence of what clinical supervision should be. It only captures the normative and formative elements of the practice and completely omits the restorative element.

There is also valid criticism that renaming clinical supervision will only increase suspicion that a management initiative is being forced upon nurses. I can see why this could be considered. However, changing the name could also illustrate that current practice is not working to achieve its intent, which is desperately sad, as developmental support is so needed in nursing to tackle retention, burnout and compassion fatigue.

Rebranding clinical supervision could be seen, as with everything in nursing, to highlight that nursing practice is evolving, as it always should. Why would we be so married to a name when a more descriptively accurate one could be used? I would hate for a desire to hold onto how things have historically been unintentionally cause failure to implement something so desperately needed for all nursing fields with organisational support and protected time.

My intention is not to be combative or obstructive but merely to question and continue the critical debate. I am such an advocate of the theory and practice implications of clinical supervision’s reflective and restorative benefits in helping to support nurses and to aid them in continuing professional development. Moreover, I have nothing but admiration for the tireless work of all at the Florence Nightingale Foundation, especially the Clinical Supervision Subject Expert Group, many of whom I know disagree with my views.

I understand that there is also a cultural barrier to the successful implementation and delivery of clinical supervision, particularly in fields outside of mental health nursing. My observation is, would it not be better to change the name to be more descriptive of what it is rather than having to explain and break down existing barriers. We know how challenging that is in nursing.

Additionally, obviously any proposed name change would need in-depth research and an impact assessment. But the fact so many nurses are identifying issues with the name, surely mean we cannot ignore them. It is positive we are having this debate, and the RCN Forum’s scoping review has launched a new springboard. I hope this matter will be discussed at RCN Congress; emergency item?

To conclude, I do not profess to have all the answers, and I see enormous benefits in the intent of clinical supervision. I think it should be a mandatory, time-protected provision for all nurses. However, I believe clinical supervision’s most significant barrier is its name. Would “Professional Support and Development” or “Professional Reflection and Development” not be much more indicative of the intent and a more appealing offer? Or, as a good friend suggested how about “Guided Reflection” with a facilitator. We all agree we need this supportive relationship as professional practitioners. But if we do not get the name right, will we continue to experience misunderstanding and failure to engage?

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