Clinical Supervision: Getting It Right!

The article ‘Enablers and barriers to effective clinical supervision in the workplace: a rapid evidence review’ presents evidence from the international literature on effective clinical supervision [1]. The review searched nearly 16000 international publications to answer the question: What makes effective clinical supervision? When in place and done well, clinical supervision has many benefits for the organisation, professional development and patient services.

The article 'Enablers and barriers to effective clinical supervision in the workplace: a rapid evidence review' presents evidence from the international literature on effective clinical supervision [1]. The review searched nearly 16000 international publications to answer the question: What makes effective clinical supervision? When in place and done well, clinical supervision has many benefits for the organisation, professional development and patient services.
In the review, a particular definition was used to help distinguish ongoing supervision from one off training sessions, often still labelled 'supervision' [2]. There is good agreement that clinical supervision should be focused on staff development, (including managing poor performance), but with the aim to drive up the service and improve patient outcomes [3]. What emerged in the literature was that there were a range of clinical supervision models, and not simply a dominant one of senior and junior hierarchy. Other supervision models offered a range of benefits i.e. group supervision offered the opportunity to learn from other colleagues about how to deal with a shared situation, having clinical supervision from a professional external to the organisation enabled a focus on staff development, or a member of staff from another profession which enabled new perspectives to be considered. However, each had downsides such as not knowing about staff performance issues or the policy directions of the organisation. Other new emergent models included distance supervision, managed online.

What Makes Effective Clinical Supervision?
The first major theme concerning what makes effective supervision is around the key role that the organisation plays. This involves ensuring that 1) supervision actually takes place, 2) that supervision is valued by the organisation, 3) that supervisors are provided with the essential training needed, and 4) protected time is given for supervision to take place. A suggestion of making supervision mandatory could be discussed to ensure the supervision is valued.
What is interesting is that many aspects of effective clinical supervision within the data were about the organisation putting various structures in place, which enables supervision to happen. If the organisation fails to recognise all the benefits of clinical supervision for staff retention, staff well-being and patient outcomes, time will not be made available and supervision will be seen as a bonus on a quiet day, rather than an essential part of staff support and development and improved services.
The second theme discusses the need to have an open, supportive and safe environment. This environment is crucial for supervisees, to ensure that they feel comfortable to discuss their personal and professional needs, alongside any ethical issues. A supervisor who is willing to meet on an ad hoc basis to respond to more urgent staff issues is also an important attribute of effective clinical supervisors. Value is placed on spending time reflecting on practice and receiving feedback. It is clear that good supervision is determined by the process of how the supervision takes place, rather than purely content. This will generate energy and enthusiasm for supervisees to be able to work through any challenges they may face in practice, and build their competence and insight.
The final and third theme, and probably one of the most important; concerns the level of trust within the relationship. This was one of the most frequent findings in the review. Effective supervision involves having a relationship with a supervisor which is based on trust. Ideally supervisees should be offered a choice of supervisor, which is important to ensure the supervisor is credible and respected. Various papers also noted the importance of sharing a cultural understanding. The purpose of clinical supervision further needs to be defined and ideally a contract should be agreed to provide clarity with each other.
Other factors leading to effective supervision included having regular, but flexible supervision that fitted around the needs of all staff (e.g. staff shift patterns), as well as providing constructive and timely feedback.

Surveillance and Monitoring
Without this agreed 'contract' , the purpose of the supervision can be unclear and in a worst case scenario, supervisees may perceive that clinical supervision is really more about surveillance than staff development. Obviously, supervision is subject to different interpretations, managers in particular also need to focus on service delivery and staff development, which may seem less important to supervisees. Therefore, agreeing on the shared purpose of supervision is essential to reduce ambiguity.
A monitoring agenda will not lead to effective supervision. Problems seem to arise when the focus of supervision was perceived to be on monitoring staff performance, rather than on the provision of support. Supervisors who are also line managers should ideally be trained to manage the individual needs of staff development alongside the needs of the service, which at times may be in conflict.

Impact on Positive Outcomes
It was clear from the review that if done effectively, there were many positive outcomes of having clinical supervision, including: being better able to cope with the demands of the job, retention, increased resilience, a better work environment, job satisfaction, reduced stress and anxiety, and better quality of care.
Obvious barriers to access were reported for those working out of office hours, at night or at weekends. Other barriers were having a heavy workload, a lack of time, private spaces and staff shortages.

Conclusion
The findings would suggest that the overall supervisory experience is not simplistic. There is a need to take into account all of the factors and levels presented, there being no single answer leading to effective supervision. This was relevant to all health care professions. So long as the purpose of supervision is agreed, and individual needs of each supervisee are assessed and identified, this should support implementation of effective supervision. The importance of this two-way relationship is highlighted in a realist synthesis by Wiese et al. [4] who demonstrated the need for a supervisor and trainee to be in a two-way process, supervision being shaped by both, and requiring leadership from both. Each profession will have their own needs too in terms of level of supervision, but this should be addressed within the issues discussed above.