Clinical supervision for NMAHPs

A rapid systematic review of research evidence

FINAL REPORT

Alex Pollock, Pauline Campbell, on behalf of the Working Group

26/11/2015

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Introduction In order inform the identification, development and implementation of a possible framework for clinical supervision in midwifery, the CNOD Chief Midwifery Advisor commissioned a systematic, comprehensive, rapid exploration of the evidence relating to potential benefits, facilitators and barriers to clinical supervision in healthcare practice.

The stages involved in this process are outlined in Figure 1, and form the basis for this report.

Figure 1: Project Workflow

Preliminary scoping review of literature - explore definitions of clinical

supervision & identify key models

Small working group meeting

Protocol for rapid systematic review

Synthesis 1 - describe clinical supervision interventions

Synthesis 2 - evidence for effectiveness of clinical supervision

Synthesis 3 - evidence relating to barriers and facilitators of implementation of

clincial supervision interventions

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Preliminary Scoping Review

AIMS To inform the protocol development and decisions of the working group, an initial scoping review of the literature was completed in order to (1) explore definitions of clinical supervision, and (2) identify key models of clinical supervision, and their features, used within healthcare settings.

METHODS This scoping review involved systematic searching of the PDQ-Evidence electronic database, from 2010 onwards, combining search terms for health professionals (including nurse, midwife and allied health professional) with terms for models of clinical supervision. Any paper reporting issues, theories, or research relating to models of clinical supervision in health professionals was identified, if it was published in English. Searching of grey literature was also completed, including Google and Google Scholar searches, hand searches of reference lists of identified papers, and references provided by experts from the work group were also included. One researcher considered all identified papers, systematically extracted any documented definition of the phrase “clinical supervision” and noting all “named” models of clinical supervision. A second researcher used the identified papers to extract summary details relating to each identified named model of clinical supervision, including a brief description of the model, any details of practical implementation (frequency, duration, mode of delivery), details of groups with whom the model had been developed and/or used.

RESULTS Multiple definitions of clinical supervision were extracted and details of models of clinical supervision identified. A mindmap was used to illustrate links and relationships between different models, with specific consideration of the focus of the model.

A full report with the results of the preliminary scoping review is available on request.

DISCUSSION / CONCLUSION The results of the preliminary scoping review were considered by the working group, and used to inform decisions relating to the development of a systematic review protocol.

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Small working group meeting

AIMS In order to develop an informed, consensual research protocol, designed to meet the aims of CNOD the results of the preliminary scoping review were presented to a small working group. This group comprised purposively selected individuals with expertise relating to midwifery, clinical supervision, and research (see Appendix 1).

METHODS The identified definitions and models of clinical supervision were considered and discussed at a meeting of the workgroup. The mind map, illustrating links and relationships between different models of clinical supervision, which was initially drafted by the researchers, was refined by expert members of the workgroup. Discussion amongst expert members led to consensus over (1) working definitions of clinical supervision which should be used within the research protocol, (2) the specific focus of clinical supervision interventions to be addressed within the research, and (3) the aims for the systematic review relating to clinical supervision.

RESULTS

Definition of clinical supervision: For the purposes of this research protocol, the agreed working definition of clinical supervision combined two established definitions:

Clinical supervision is "a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety in complex situations” (DoH 1993). Further, “clinical supervision provides a route to developing and maintaining emotionally healthier individuals in an emotionally healthier workforce culture. Effective systems of clinical supervision can bring benefits not only to practitioners but also to the organisation and its clients” (Bond & Holland (1998, pxii) cited in 1).

Focus of clinical supervision interventions to be addressed within research:

Systematic exploration of existing models of clinical supervision identified through the preliminary scoping work and considered by the work group led to consensus that, clinical supervision interventions to be further addressed within the research protocol must:

a) Be based on theoretical or empirical-based models

b) Meet the working definition of clinical supervision (as above)

c) Have documented evidence of use within clinical practice by nurses, midwives or allied health professionals (NMAHPs1).

1 NMAHPs defined as health and care professionals regulated by the Health and Care Professionals Council (HCPC): Arts therapists, biomedical scientists, chiropodists / podiatrists, clinical scientists, dieticians, hearing aid dispensers, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, practitioner psychologists, prosthetists / orthotists, radiographers, social workers, speech and language therapists.

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These criteria will therefore exclude focus of clinical supervision interventions that are exclusively focused on:

• The supervisee only. These clinical supervision interventions often have a focus specifically on resilience building, and may be based on models of restorative supervision.

• The supervisor role. This excludes a number of models specifically focused on processes or actions of the supervision.

• Education. There are a number of specific models and interventions focused on clinical supervision during educational courses or programmes, which will be excluded.

Research aims: In order to inform the identification, development and implementation of a framework for clinical supervision in midwifery, a systematic review of current research evidence is required to address the following aims:

1) Describe the practical implementation of clinical supervision interventions for NMAHPs

2) Determine the evidence of the effectiveness of clinical supervision interventions on objective outcomes, including: cost, complaints, staff sickness, retention, adherence, acceptance and perceived usefulness

3) Identify key barriers and facilitators to implementation of clinical supervision interventions.

DISCUSSION / CONCLUSION Following the working group meeting a research protocol for a systematic review meeting the agreed research aims was drafted. This was circulated amongst members of the working group, discussed during a teleconference and further refinements and clarifications made. A final version of the systematic review protocol was agreed prior to commencement on the systematic review.

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Protocol for rapid systematic review A detailed research protocol was developed to address the aims agreed by the Working Group (see above).

Figure 2 briefly outlines the plan, and results, for identification of included studies and 3 sequential sequences.

FIGURE 2: Identification and inclusion of studies within 3 planned syntheses

The full protocol is available as a separate document.

The results of the 3 planned syntheses are detailed in the following sections.

Studies potentially meeting selection criteria –

143 full papers assessed

Electronic search results – 2994 titles considered

Potentially relevant studies – 583 abstracts considered

2411 obviously irrelevant results excluded

440 studies not meeting selection criteria

excluded (with reasons)

57 studies not meeting selection criteria (with

reasons) Included studies – 48 primary studies (57 papers)

+ 26 reviews

Synthesis 1: Describing clinical supervision

interventions – 48 studies included

Synthesis 2: Studies evaluating effectiveness of clinical supervision –

26 reviews included

Synthesis 3: Studies reporting barriers &

facilitators to implementation – 45

studies included

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Synthesis 1: Describing clinical supervision interventions

AIM: To describe the practical implementation of clinical supervision interventions for NMAHPs.

METHODS: The methods are described in the systematic review protocol.

RESULTS

1.1 Studies of clinical supervision 48 studies relating to clinical supervision were identified and included. These included a variety of different study designs. Few of the included studies clearly described the implementation of a clinical supervision intervention; in many cases the studies were primarily exploring how clinical supervision was being implemented in practice, rather than aiming to implement a detailed intervention.

We applied a ‘traffic light’ system to rate the quality and comprehensiveness of the description of the clinical supervision intervention in these 48 included studies. Table 1 details the judgement on the quality / comprehensiveness of the descriptions of clinical supervision and the designs of the included studies. Only 19 of the 48 studies were judged to have some details of the clinical supervision intervention, with 3/48 were rated as “green” 2-4 and 16/48 as “amber”. The study designs varied although almost half (23/48) were surveys or questionnaires.

Type of study design

Traffic light rating of quality / comprehensiveness of description of clinical supervision Number of studies

Comprehensive description of clinical supervision intervention, with few missing data. Details ought to be sufficient to facilitate replication.

Details of some areas of the clinical supervision intervention well reported, but absent for some areas. Details would not be sufficient to facilitate replication, but could be integrated into an intervention with similar characteristics.

Few details provided and/or inadequate description of the clinical supervision intervention. Details would not be sufficient to facilitate replication of the intervention.

Action research 4 0 1 3 Case report or study

5 0 3 2

Cohort study 1 0 1 0 Mixed methods 5 0 3 2 Qualitative study

5 0 2 3

Clinical trial 5 1 3 1 Survey/questionnaire

23 2 3 18

TOTAL 48 3 16 29 TABLE 1: Study design and quality / comprehensiveness of description of clinical studies within included studies

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1.2 Studies with descriptions of clinical supervision interventions Nineteen of the 48 identified studies were judged to contain some details relating to the clinical supervision intervention (i.e. rated as ‘green’ or ‘amber’). The remainder of this synthesis is therefore focused on these 19 studies only. A summary of these studies is provided in Table 2.

Study Country of study

Study design Setting Supervisees Number participating in study, as supervisees

Bailey 20145 Australia survey / questionnaire Varied (e.g. private practice, non-Government roles and community based roles)

Counselling practitioners

8

Bambling 20066 Australia RCT Mental health services

Volunteer therapists

unclear

Bergdahl 20117 Sweden action research Hospital-based advanced home care unit

Registered nurses 7

Bowers 20078 UK case report or study Community District nurses 7 Brink 20129 Sweden Qualitative Ambulance services Ambulance nurses

and technicians 10

Brunero 20123 Australia survey / questionnaire Hospital Nurses 9 groups Buus 20134 Denmark survey / questionnaire Psychiatric wards mental health

nurses 2 groups

Chilvers 200910 UK case report or study Specialist palliative care

Registered nurses (RNs), health-care assistants (HCAs) and community associate practitioners (CAPs)

(12 supervisors)

Cross 201011 Australia Qualitative High dependency ward

Nurse Unit managers

6

Cross 201212 Australia case report or study Outreach Outreach nurses 2 Dawber 201313 Australia Mixed methods Mixed clinical

nursing specialities Nurses & midwives

(3 groups)

Evans 201514 UK survey / questionnaire Not-for-profit social enterprise

Clinical staff unclear

Girling 200915 UK survey / questionnaire Children's hospice Clinical staff unclear Gonge 20152 Denmark RCT Psychiatric wards Permanent

nursing staff (qualified and auxilliary)

83

Heaven 200616 UK RCT Community Clinical nurse specialists

61

Livni 201217 UK Cohort study Alcohol health service

Nurses, psychologists, social workers, counsellors

37

O'Connell 201118

Australia Mixed methods Hospital wards General nurses (2 supervisors)

Turner 201119 UK Mixed methods NHS nursing care Nurses "very small sample" White 201020 Australia RCT Mental health

services Mental health nurses

(24 supervisors)

TABLE 2: Overview of studies with descriptions of clinical supervision interventions

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1.3 Models of supervision There are a number of models of supervision. The most frequently cited model of supervision which describes the content is Proctor 200021, 22 (see Table 3), with 8/19 studies specifically referring to Proctor’s Model. The three “functions” of clinical supervision as described by Proctor 200022 are shown in Table 4.

Model Studies No. of studies

Proctor’s model21, 22 • Bowers 20078 • Brunero 20123 • Gonge 20152 • Evans 201514 • Turner 201119

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Reflective models • Chilvers 200910 • Dawber 201313 (also cites Proctor)

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Other • Bailey 20145 (Lowe & Guy 1996) • Bambling 20066 (Working Alliance) • Brink 20129 (“collegial group supervision”) • Buus 20134 (Bond & Holland, 2010; Hawkins & Shohet, 2006) • Heaven 200616 (Bandura’s social cognitive learning) • Livni 201217 (Supervisory alliance)

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Various • Cross 201011 (includes Proctor 2000, Driscoll 2000) • White 201023 (includes Proctor and reflective practice)

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Not stated / unclear • Bergdahl 20117 • Girling 200915 • Cross 201212 • O’Connell 201118

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Total 19 TABLE 3: Models of clinical supervision cited in included studies (19/48 studies ranked as ‘green’ or ‘amber’).

Normative Maintaining appropriate standards of care and monitoring quality.

Formative (educational) Developing knowledge, skills, research awareness and understanding. Done through problem solving, with the supervisor sharing knowledge and expertise, identifying training needs, reflection and exploring other perspectives.

Restorative (Supportive) Creating a therapeutic relationship that nurtures and cares for the person being supervised. It facilitates self-awareness through critical analysis and exploration of events and feelings.

TABLE 4: Functions of clinical supervision (Proctor’s model). From Evans 201514

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1.4 Mode of delivery Table 5 details the mode of delivery of the 19 studies. The majority of studies focus on group supervision (12/19). This is generally led by a facilitator, but occasionally is peer-led (Cross 2010)11. Brunero 20123 justified the choice of group supervision, over one-to-one supervision, stating that:

"Group supervision was chosen over individual as it was the most pragmatic of options given the size and volume of nurses within clinical areas".

Mode of delivery Group supervision One-to-one (individual) supervision

Either group or individual, or mixed

Study Bailey 2014 5, Bergdahl 20117, Bowers 20078, Brink 20129, Brunero 20123, Buus 20134, Gonge 20152, Chilvers 200910, Cross 201011 , Dawber 201313, O’Connell 201118, White 201023

Bambling 20066, Cross 201212, Girling 200915, Heaven 200616, Turner 201119

Livni 201217, Evans 201514

No of studies 12 5 2 TABLE 5: Mode of delivery of clinical supervision

All clinical supervision interventions were delivered face-to-face.

Evans 201514 specifically planned to enable a range of different modes of delivery, stating that “A menu of 6 options was provided to enable supervision to be adaptable and tailored to individual staff & service needs.” (see Table 6).

Dawber 201313 identified that a number of different types of groups could be used for clinical supervision sessions. These are described as “open” (attended by any eligible staff on duty/available at the time) or “closed” (attended by specified staff only). A closed group may operate a system where all group members attend every meeting, or a system where group members only attend when they are on duty/available at the time. The groups can also vary in relation to the structure and style of facilitation.

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Clinical Supervision Menu

Minimum standards for a 12-month period

Option A: group supervision

In a 12-month period, six group-facilitated supervision sessions equals 100% clinical supervision. Groups meet every six to eight weeks so a clinician may attend more than six. Reflective logs are recommended and complement sessions.

Option B: reflective log In a 12-month period, a clinician should complete a minimum of six reflective logs and discuss/provide evidence of resultant learning in their one-to-one meeting/appraisal. This would constitute 100% clinical supervision. This is only an option if critical challenging and support are available from the clinician’s team or manager. Managers supporting a clinician who has opted for reflective logs must ensure the process remains supervisee led.

Option C: (for highly specialised roles only)

Clinical specialist/peer supervision is for practitioners in an expert specialist role, usually at band 6 and above. Such practitioners may access supervision from one or more other specialists in their clinical area from outside or within the organisation. As with group supervision, six sessions in 12 months constitutes 100% clinical supervision and reflective logs complement learning from clinical specialist supervision.

Option D: peer review Two peer reviews in 12 months constitute 100% clinical supervision. Option E: action learning sets

Action learning sets will meet every six to eight weeks for a period of 12 months; six action learning sets in 12 months therefore constitutes 100% clinical supervision. Clinicians should consider commitment to the learning set they join and the importance of attending each set. Meetings will be booked by individual sets every six to eight weeks depending on their individual needs.

Option F: blended approach

Staff are able to mix the options to make up 100% requirement. Example 1: Staff may complement their existing clinical expert/peer supervision arrangements with reflective logs or peer reviews. Note: If a commitment is made to a group, a member of staff cannot opt out of it to access another option from the menu as this is disruptive to a group. Example 2: Staff may combine peer reviews with reflective logs; this can be done to make up the 100% supervision requirement.

TABLE 6: Menu of clinical supervision options provided by Evans 201514

1.5 Frequency and duration of sessions There is surprisingly little evidence available regarding the frequency of participation in clinical supervision. The frequency of clinical supervision can be measured as the number of sessions conducted or, more specifically, as the number of sessions an individual nurse has attended (Gonge & Buus 2010)24.

Group sessions were delivered between once a week and every 8 weeks, and varied between 45 minutes and 2 hours in length (see Table 7). One to one sessions varied from a 1 hour session once a fortnight, to a 1 hour session once every 3 months (See Table 8). One study reported a total of 12 hours supervision delivered as four ½ day sessions over a four week period (Heaven 2006)16; in this study clinical supervision was delivered specifically with the aim of supporting transfer of communication skills training into clinical practice, potentially accounting for the greater duration of delivery. Another study reported clinical supervision which occurred after each client (Bambling 2006)6, but this was delivered in the context of a randomised controlled trial, with the aim of supporting adherence to a specific treatment protocol.

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Study Frequency of clinical supervision Duration of session Bailey 2014 5 "group would meet one evening per month" 90 minutes

Bergdahl 2011 7

13 sessions with approximately 5 weeks between the sessions 2 hours

Bowers 20078 Monthly 2 hours

Brink 20129 NS NS

Brunero 20123

Fortnightly to monthly "dependent on the clinical area" 1 hour

Buus 20134, Gonge 20152

Three sessions: introduction (3 hours) followed 6 weeks later by two follow-up sessions (lasting one hour each)

Varied (manual described an intervention with three sessions: introductory session lasting three hours and, at about six weeks interval, two follow-up sessions lasting one hour each)

Chilvers 200910 Every 8 weeks Six sessions; length of session NS

Cross 201011 Weekly 15 sessions, 1 hour length over 6

months

Dawber 201313

Model 1 = alternated between fortnightly and monthly sessions. Model 2 = between fortnightly and monthly, based on perceived need. Model 3 = fortnightly.

Model 1 = 45mins. Model 2 = 1hr. Model 3 = 1hr.

O’Connell 201118 Weekly 1hr

White 201023 Monthly 45-60 minutes

TABLE 7: Frequency & duration of group clinical supervision

Study Frequency of clinical supervision Duration of session Cross

201212 Fortnightly 1 hour sessions, delivered over 12 months

Girling 200915 Every 3 months 1hr

Heaven 200616 Four 1/2 day sessions Total of 12 hours, delivered over 4

weeks Bambling

20066 After each client (treated within a RCT) NS

Turner 201119 Usually monthly NS

TABLE 8: Frequency & duration of one-to-one clinical supervision

In Livni 201217 supervisors and supervisees were randomly allocated to either individual or group supervision conditions. The individual supervision sessions ran for 60 minutes, while small group supervision sessions ran for 90 minutes, with a range of 2-8 sessions over the 6 month project period. The frequency of clinical supervision proposed by Evans 201514, for a range of modes of delivery, is stated in Table 6.

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1.6 Was clinical supervision voluntary or mandatory? In the majority of the studies (9/19) participation in clinical supervision was voluntary. In one study it was stated that participation was not mandatory, but that staff were “strongly advised to attend" (Chilvers 2009)10, while in another it was mandatory for participants in one setting (ward), and voluntary in another (Buus 2013)4. In two studies participation required consent for ethical reasons associated with the study design (Heaven 200616, White 201023), and information was unclear or not stated in three studies.

1.7 Content & structure of sessions Few studies provided a comprehensive description of the content of the sessions and how these were structured; Table 9 details the descriptions perceived to be most comprehensive or informative.

Two of the studies specifically referred to the establishment of “ground rules” at the start of the clinical supervision process (Bowers 20078, Turner 201119); the detailed ground rules proposed by Bowers 20078 are in Table 10. Some studies either implicitly or explicitly described a process in which a “problem” or “issue” was raised and then explored by the mentee; this is proposed as a circular model by Brunero 20123 (Figure 3).

Study Description of content/structure of clinical supervision session Bowers 20078

"Members defined some specifically focused ground rules: Participation, confidentiality, Content of discussions, Chair, sensitive subjects, Action plans and Minutes of forum (see Table 9 for more details). Individuals were invited to discuss ‘any clinical issue within their working day’”

Cross 201212

"Supervisor helped them formulate the problems they encountered and to facilitate a way of approaching the problems in a practical manner. Their experiences would then become ‘grist for the mill’ and form the basis for the next session."

Dawber 201313

Clinical supervision "groups focus on the interpersonal aspects of care delivery, and aim to encourage and empower participants to promote this perspective in their clinical work" Three different structures were used within three different groups: Model 1 = semi-structured group with an active facilitation style. 3-10 people, consisting of nurses on duty at the time (plus any casual and student nurses). Model 2 = group of 6-7 midwives working in 'continuity of care' model. Closed group. Little structure and less active facilitation style. Model 3 = 6-8 oncology nurses. Closed group. Attended by permanent nurses able to attend on the day (no casual staff or students). Active, structured facilitation style.

Turner 201119

Began by developing a "supervision ‘contract’ negotiation, use of an information pack on clinical supervision, and beginning the development of the supervisory relationship. The contract negotiation involved setting ground rules of clinical supervision: venue, confidentiality, objectives and documentation"

Brink 20129

The supervision process followed a "template developed by Pertoft and Larsen (2003)."

Cross 201011

"CS usually began with an ‘open ended’ statement such as, ‘Well, how have things been this week’? Often the nursing staff would have a pressing problem that they wished to discuss, such as a ‘difficult’ patient or a stressful shift. This issue would them become the key topic for discussion during the session".

Bambling 20066

In the “process supervision condition, case discussion focused on assisting therapists to develop an understanding of the interpersonal dynamics occurring during the therapy……..case discussions focused on monitoring implicit client feedback, changes in client anxiety level, flow of exchanges, resistance, and perceived dynamics in the relationship with the therapist………….Supervision case

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discussion was used to identify client behaviors or characteristics likely to hinder or advance therapy by examining explicit client feedback from session to session, satisfaction with therapy, level of comfort with the therapist, and clarity of therapy goals and client tasks. Therapists were given explicit advice and guidance concerning the kinds of behaviors and interventions likely to enhance alliance”.

Evans 201514

A menu of 6 options was provided to enable supervision to be adaptable and tailored to individual staff & service needs (Table 6)

Brunero 20123

Details a circular model including seven stages: 1) identify key issue; 2) define and describe; 3) critical analysis; 4) Examine solutions; 5) Formulate action plan; 6) implement; 7) evaluate (see Figure 1 for model).

O’Connell 201118

“The focus of the sessions was driven by the participants themselves. Sessions often started with a general discussion about how everything was going on the ward and whether there were any issues or concerns (e.g., clinical, interpersonal, etc) that staff wanted to discuss. All participants were encouraged to share their opinions and experiences related to the particular issue, consider factors that tend to improve and/or worsen the situation, and identify strategies and solutions to resolve the issue. In this way, the solutions were also driven by the participants.”

TABLE 9: Descriptions of the content or structure of clinical supervision

Ground Rule Description Participation The forum belongs to every staff nurse and it is up to each person to decide

its direction. Confidentiality The content of discussions in the forum remains confidential between the

members of the group. If unsafe or unprofessional practice is disclosed, members will support each other in formalising, at the time, how the individual concerned (or other member of staff) will bring these issues to the attention of the person’s line manager.

Content of discussions

Every member is invited to bring up any clinical issue within their working day that they would like to discuss with peers. There will be no negative criticisms of personalities within the sessions. All members are invited to give feedback on a subject.

Chair: The chair of each forum is to rotate between members. The chair’s responsibility is to ensure that each member of the forum has a chance to openly express his or her views. It is also the chair’s role to move discussions on from a subject depending on the time restraints and the subject’s complexity and/or sensitivity.

Sensitive subjects

The group will access an outside clinical supervisor if members want to explore a sensitive subject. It is down to members to decide when a subject is sensitive and to leave the topic until the next session when an outside supervisor can facilitate the discussion.

Action plans The group is to decide what actions are to be taken as a result of their discussions and how this is to be fed back in future sessions and to other members of the district nursing teams.

Minutes of forum

Brief and non-detailed minutes of the forum will go to each member.

TABLE 10: Ground rules for group clinical supervision, from Bowers 20078

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FIGURE 3: Structure/content of clinical supervision (from Brunero 20123)

1.8 Supervisors Clinical supervision was either facilitated by a range of different people, with very varied levels of experience in clinical supervision (see Table 11). The training provided to clinical NMAHPs comprised a 2-day university course tailored to the supervisor’s needs (Chilvers 2009)10 and a 4-day “residential, intensive, experiential” course combining practical exercises with theory-based seminars (White 2010)23. Bambling 20066 provided one training session and a manual, but all supervisors in this study had to have previously had at least 2 years experience of providing clinical supervision. Brunero 20123, Buus 20134 and Gonge 20152 all provided supervisors with a written manual, or handbook, detailing the role and functions of Clinical Supervision.

Type of supervisor

Clinical NMAHPs who had attended training

Trained clinical supervision facilitator

Group members, lead person rotating between members

Other Unclear / not stated

Group clinical supervision studies

Chilvers 200910 White 201023

Cross 201011 Dawber 201313 O’Connell 201118

Bailey 2014 5 Bowers 20078

Brunero 20123 (co-facilitation, with 2 facilitators) Buus 20134 (researcher) Gonge 20152 (researcher)

Bergdahl 2011 7 Brink 20129

One-to-one clinical supervision studies

Bambling 20066 Cross 201212 Girling 200915

Heaven 200616 Turner 201119 (line manager)

Heaven 200616

Mixed Evans 201514 Livni 201217

TABLE 11: Details of supervisors for clinical supervision.

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For the studies which provided a mix of either group or individual supervision, the clinical supervision was provided by clinical NMAHPs (Evans 201514 and Livni 201217). NMAHPs in Livni 201217 attended knowledge and skills training workshops, whilst Evans 201514 stated:

“All clinical staff are encouraged to attend one introductory workshop, which continues to be offered bi-monthly. After initial training, group facilitators are supported in their role through allocation to a self-facilitating supervision group for facilitators. This offers support and a safe environment in which to discuss and reflect on issues relating to the management of the group they facilitate as well as clinical issues relating to their role.”

1.9 Documentation of clinical supervision sessions There was very little information provided in the studies in relation to whether (or how) clinical supervision sessions were documented. Two studies stated that records or notes were kept by the supervisors (Livni 201217, Cross 201011), one mentioned minutes of meetings (Bowers 20078), another used standard forms (Chilvers 2009)10, and another stated that:

"Documentation included three sheets, first negotiating the contract, second the sessional plan and third a record of clinical supervision" (Turner 2011)19

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Competent midwife

Normative, formative and restorative functions

Reflection on practice

Figure 4: Midwifery model of professional supervision (Calvert 2014)

1.10 A “midwifery model of professional supervision” (Calvert 2014) Following the pre-planned completion of Synthesis 1, during completion of Synthesis 2 we identified a further paper (Calvert 2014)25 which describes a “midwifery model of professional supervision”. This paper did not meet the original criteria for inclusion in Synthesis 1 (as it was classed as a systematic review and not a primary research study). However discussion amongst the Working Group, following our pre-planned iterative approach, led to the conclusion that this paper contained potentially valuable descriptions of a supervision model which was highly relevant to our research question. Two members of the Working Group (Professor Ruth Deery and Dr Mick Fleming) critiqued this paper, concluding that – while there is a risk of bias associated with the inclusion of a paper which did not meet our pre-planned inclusion criteria (i.e. selection bias) - the detail within this paper and its relevance to recertification and regulation (which is considered not dissimilar to present UK policy for midwives and registered nurses) supports the rationale for the discussing this paper within Synthesis 1 (see Appendix 2).

In the midwifery model of professional supervision proposed by Calvert 201425, a model is proposed in which a competent midwife2 is one who participates in functions as defined within Proctor’s model, and reflects on their practice. This is illustrated in Figure 4.

Table 12 details how the practical implementation of the normative, formative and restorative functions are described, and Table 13 the proposed process of reflection on practice.

In relation to practical application of reflection on practice during a supervisory session, Calvert 201425 states:

“For midwifery using a cyclic process in a reflective professional supervisory session the midwife would be required to describe an event, by a process of observational reflection explore how she thinks and feels about the situation, explains what was positive or negative about the experience, analysis the meaning or significance of the event, consider if anything else could have been done and decide what has she learnt from the experience that would assist her to cope should the same or similar situation occur again.”

The role of the supervisor is described as:

“one of facilitator rather than expert who help the supervisee to explore the issues of concern and link theory to practice. In the reflective learning model the supervisee is responsible for their own learning however if issues of safety arise then the supervisor should take the dominant role.”26

2 Defined in the paper as: A autonomous professional midwife who has met the requirements of the Midwifery “Council of New Zealand’s recertification programme and demonstrated competence across the scope of practice”.

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Further it is highlighted that

“the supervisor must be the facilitator of learning, listen to the supervisee, challenge them to become critical thinkers, develop new ideas and question their environment”.

Appendix 3 contains the “Recertification Programme and Summary” as this provides an illustration of the documentation used during the implementation of this model.

FUNCTION WHAT IS REQUIRED DETAILS Formative (educative)

Compulsory education Set by council every three years Elective education Completion of courses that are approved by council and allocated

points accordingly. May also apply discretionary points to courses that are not approved.

Normative (managerial)

Scope of practice Portfolio of reflective case studies with evidence of dates and locations

Professional activities ‘‘Professional activities are additional roles or responsibilities that midwives engage in which broaden and develop the individual midwife but which also enhance the midwifery profession’’28 (p. 2). Such activities include attending New Zealand College of Midwives Regional Monthly meetings or presenting at conferences.

Midwifery Standards Review

Involves the midwife reflecting on her practice, describing how she meets the standards for practice as well as her practice statistics. It is also an opportunity to identify gaps in knowledge and/or skills and how these will be addressed. Maintaining a professional portfolio as evidence of participating in the recertification programme and presenting it for audit when requested by MCNZ is also a competency requirement. The MSR and the Audit are surveillance activity on behalf of the Midwifery Council.

Restorative (supportive)

Focus on the emotional impact on the midwife as a result of working in the current healthcare environment.

Assists the supervisee to process the experience. Reflection on the value of these sessions is required and should be part of the midwife’s portfolio.

TABLE 12: Formative, normative and restorative functions as described within the Midwifery Model of professional supervision25.

Reflection on: Details Education sessions (formative function)

Required to demonstrate what the midwife thinks she has learnt and feels about the course undertaken. This reflective component is a vital part of experiential learning for without it transformation, which implies new knowledge or finding meaning for the event, cannot occur.

Professional activities (normative function)

A midwife is required to reflect on her own practice and professional activities, considering how she meets standards for practice and on how her learning has been demonstrated.

Supportive (Restorative function)

Professional supervision assists the supervisee to process the experiences and emotional impact of working in the current healthcare environment. Reflection on the value of these sessions is required and should be part of the midwife’s portfolio.

TABLE 13: Reflection on practice as described within the Midwifery Model of professional supervision25.

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DISCUSSION AND CONCLUSIONS Synthesis 1 aimed to synthesise descriptions of clinical supervision interventions for NMAHPs. While there are significant numbers of published papers relating to clinical supervision, descriptions of the practical implementation are generally very poor.

Key components of clinical supervision for which descriptions have been synthesised are summarised in Table 12, below:

Component of clinical supervision

Summary of descriptions available in studies

Models of supervision (see 1.3) There are a number of “models” of clinical supervision. Proctor’s model appears to be used most frequently. Proctor’s model identifies 3 ‘functions’; normative, formative and restorative.

Mode of delivery (see 1.4) Clinical supervision can be delivered to groups or individuals (one-to-one). Groups may be ‘open’ or ‘closed’. In some cases a range, or menu, of different modes are offered, to enable tailoring to staff and service needs.

Frequency & duration of sessions (see 1.5)

There is little evidence available, and substantial variation. Group sessions are delivered between once a week and every 8 weeks, and varied between 45 minutes and 2 hours in length. One to one sessions varied from a 1 hour session once a fortnight, to a 1 hour session once every 3 months

Voluntary or mandatory clinical supervision (see 1.6)

Both options have been used, although voluntary involvement has been reported most frequently.

Content & structure of sessions (see 1.7)

Few studies provided a comprehensive description. ‘Ground rules’ may be established at the start of the process. The session may be considered as a circular process in which a problem or issue is raised and explored.

Supervisors (see 1.8) Clinical supervision has been facilitated by a range of different people including clinical NMAHPs who have attended some sort of training, a trained (expert) clinical supervisor, or by member of a group who each take a turn at the role.

Documentation of clinical supervision sessions (see 1.9)

Very little information is available. Minutes, records and use of standard forms have been reported.

TABLE 12: Summary of descriptions of clinical supervision

A “Midwifery Model of Professional Supervision” has been detailed based on the context of midwifery in New Zealand, and this may provide a useful example of practical application, which could have relevance to issues of recertification and regulation within the UK.

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Synthesis 2: Evidence for effectiveness of clinical supervision AIM: Determine the evidence of the effectiveness of clinical supervision interventions on objective outcomes, including: cost, complaints, staff sickness, retention, adherence, acceptance and perceived usefulness.

METHODS: The methods are outlined in the systematic review protocol. However, in accordance with the Arksey and O’Malley (2005)27 framework, we adopted an iterative process, with regular discussion meetings of the working group to review progress, clarify aims, and agree any modifications. Use of this framework led to a number of changes to the methods used for synthesis 2.

The original protocol stated that we would identify and synthesise “primary research studies, or reviews synthesizing primary research studies”. During the process of this synthesis we noted that:

(a) there were a relatively large number of existing systematic reviews of evidence relating to clinical supervisions; the conclusions of these reviews were in agreement.

(b) there were relatively few primary research studies which included quantitative effect data; the quality of many of these research studies was limited; there was considerable heterogeneity within these studies. The reviews which we had identified confirmed this finding.

Consequently it was agreed that there was no justification for synthesising primary research studies, and that this would be poor use of the available time for these rapid reviews. Synthesis 2 was therefore limited to a synthesis of reviews of primary research studies relating to the effectiveness of clinical supervision.

RESULTS:

2.1 Reviews relating to Clinical Supervision 26 literature reviews relating to clinical supervision for NMAHPs were identified. However 16 of these were later excluded (see Table 13 for reasons).

Reason for exclusion Number of reviews Reviews Did not meet criteria to be considered a ‘systematic’ review

12 Lennox 200828, MacDonald 201229, Mills 200530, Ross 201331, Turner 201132, Wright 201233, Cummins 200934, Cleary 201035, Calvert 201425*, Bland 200536, McCloughlen 200637, Fone 200638

Did not meet our pre-stated definition of clinical supervision

2 Sirola-Karvinen 200639, Duffy 200740

Judged not to be relevant to our research questions

1 Berggren 200541

Search end date was before 2005 1 Sloan 200542 Total = 16/26 TABLE 13: Reviews excluded from synthesis 2. *Calvert 201425, while not considered a systematic review, was judged to be highly relevant to our project, and data from Calvert 201425 are therefore considered within Synthesis 1.

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Ten reviews relating to clinical supervision were therefore included. Characteristics of these reviews are summarised in Table 14 (Appendix 4).

Of these 10 reviews, 5 43-47 were judged to be at high risk of bias and therefore not considered to add further insight in relation to our specific question. These reviews primarily provided discursive narrative syntheses. Thus there are 5 systematic reviews that are judged to be a low risk of bias and relevant to our review question. These are summarised in Table 15.

Review Focus Included studies Conclusion Buus 2009 48

Clinical supervision in psychiatric nursing. Empirical studies.

25 studies

No convincing empirical evidence to support clinical supervision

Dawson 2013 49

Clinical supervision for AHPs

33 papers (including 8 reviews)

Significant gap in clinical supervision research for AHPs

Dilworth 2013 50

Critical interpretive synthesis of clinical supervision literature

59 studies No strong evidence in support of clinical supervision and diverse evidence base. Some suggestion of benefits associated with clinical supervision for staff and patients.

Francke 2012 51

Effects of group supervision for nurses

17 studies All studies indicated that group supervision produced to a greater or lesser extent certain positive effects. However, the outcome variables varied and not all studies pointed in the same direction.

Ducat 2015 52

Supervision for AHPs in rural areas

5 studies Paucity of primary research in this area.

TABLE 15: Summary of systematic reviews relating to effectiveness of clinical supervision which were judged to be at low risk of bias.

DISCUSSION AND CONCLUSIONS All of the evidence from reviews of clinical supervision (including those judged to be of low and high risk of bias, and those judged not to be ‘systematic’ reviews) are in clear agreement that:

• There is lack of agreement over what clinical supervision is or how it should be performed • There is no convincing empirical evidence to support clinical supervision for NMAHPs • Some evidence of limited quality does suggest benefits associated with clinical supervision,

but this is conflicting, and the evidence lacks details. Many barriers associated with delivery of clinical supervision to NMAHPs are identified, and exploration of these may be useful (see Synthesis 3).

Note: In Synthesis 1 we identified a relatively large proportion of primary research studies which were surveys or questionnaires (23/48). These studies do not contain evidence directly relating to evidence of effectiveness of clinical supervision interventions (instead documenting data relating to current practice and perceptions of current practice), and were therefore not included in Synthesis 2. However, in the absence of evidence of effectiveness, these data may provide some useful insights. It was beyond the scope of this rapid review to extract and explore this body of survey data, and this could be considered as a follow-up piece of work.

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Synthesis 3: Barriers and facilitators to implementation of clinical supervision AIM:

Identify key barriers and facilitators to implementation of clinical supervision interventions.

METHODS:

The methods are described in the systematic review protocol.

RESULTS: Of the initial 48 studies identified in synthesis, we were able to extract data from 45 studies (related to 61 full -text papers) 2-8, 10-13, 15-19, 23, 32, 53-95

Barriers and facilitators, based on the SURE framework (see systematic review protocol), are grouped according to whether they are:

• Reported by supervisees (section 3.1, Figure 5, and Table 15 in Appendix 5) • Reported by supervisors (section 3.2, Figure 6, Table 16 in Appendix 6) • Reported at a health systems level (section 3.3, Table 17 in Appendix 7) • Reported at a social and political level (section 3.4, Table 18 in Appendix 8)

3.1 Barriers and Facilitators reported by supervisees A large number of barriers and facilitators were reported by supervisees, across all studies. The key themes are summarised in Figure 5, and briefly described below. Themes, subthemes and data extracted (evidence) is provided in Table 15 (appendix 5).

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FIGURE 5. Mindmap of selected barriers and facilitators to clinical supervision as reported by Supervisees. (See Table 15, Appendix 5 for more detail)

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3.1.1. Barriers Common barriers to effective clinical supervision included (listed alphabetically):

• Attitude/culture – negative attitudes towards, perceptions about, and the value placed on clinical supervision, as well as a negative culture of supervision were all reported as barriers. Negative culture of supervision could be related to previous experiences of supervision, leading to perceptions that it was an unproductive process.

• Boundaries – being allocated a supervisor, rather than choosing one’s own, was perceived as a barrier, and having a line manager as a supervisor was also a barrier to effective clinical supervision and some supervisees had a misconception that the line manager ought to be the supervisor. Lack of clarity about the purpose of clinical supervision was a commonly reported barrier.

• Confidentiality and trust – anxieties and concerns about confidentiality was a commonly reported barrier.

• Individual / personal factors which were reported as barriers included challenges dealing with the cognitive demands of the process, collegiality or comradery which threatened the process, fear, lack of confidence, dealing with feedback. Problems with the supervisory relationships and a potential power imbalance were also reported barriers.

• Knowledge and skills relating to clinical supervision could cause barriers. o The knowledge that there was a lack of empirical evidence for clinical supervision meant

that clinical supervision was not seen as ‘credible’6 o Concerns relating to the need for education and training to support high quality

supervision, and the expertise and knowledge of the supervisor were all reported as barriers. A supervisor’s knowledge and background were considered important by the participants ("the supervisor is well read in nursing theory and has a solid background in the profession itself; that is the strength of this group supervision"). Other studies reported that participants thought that having a different clinical background from their clinical supervision partner was not a problem 31.

o Several studies identified lack of knowledge or a mismatch in supervisors expertise and knowledge as a barrier to CS3. Brunero (2012) also highlighted the challenge of implementing clinical supervision (CS) in hospital settings because of the ”broad range of nursing specialties within large hospital-based” 3

o Other barriers related to the interaction between level of expertise and knowledge of supervisor and supervisee to enhance professional development ("supervisor did not know local procedures and their impact on the trial and that it was difficult for supervisor and supervisee located at long distance from each other.58)

• Logistics and organisational factors accounted for a large number of reported barriers. o These commonly included issues such as lack of time and location or venue of meetings,

poor communication and supervisory availability: “Well, you are a little torn about it. I know, with my head, that it is very important we have supervision. You go and it’s been healthy and you speak about it afterwards. Usually you gain something, but if we are only four at work and everything is in flames, I start thinking that we need to cancel. It is so annoying and you have been frustrated about it and think: ‘That damn supervision’.” 96

o The mode and delivery of clinical supervision were also commonly cited barriers. Views about mode of delivery was mixed; some supervisees reported that they would prefer ‘one-to-one’ supervision as opposed to group supervision 53. Other studies showed a

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preference for group supervision stating, “being part of a group gives a sense of connectedness and reduces feelings of isolation”5

o Non-attendance or lack of engagement of other members, unclear/unhelpful documentation, the composition of the group, and workplace factors also created barriers.

o A common complaint was poor administration; there was "Confusion about times and places" so that supervisees did not “realize that “innovation was up and running”53

o Accommodation or a lack of confidential space to hold sessions was reported as a barrier in several studies.

• Resistance to change and lack of motivation were commonly reported barriers, with supervisees being reluctant to engage actively in the process. This tended to related to the perceived value of clinical supervision.

• Session content and structure were cited as barriers. This is illustrated here: “Some felt that the sessions had been ‘just grumbling’ rather than constructive, and because of staff shortages and re- organization within the PCT, sessions had focused too often on crisis management rather than looking at clinical issues"53

• Terminology was a commonly cited barrier, with the term “clinical supervision” often perceived as unhelpful, and the lack of clarity around definitions seen as a barrier. Some suggest the term “supervision” itself is problematic.

3.1.2 Facilitators Common facilitators to effective clinical supervision included (listed alphabetically):

• Attitude/culture – If clinical supervision was valued, perceived to be important, and the supervisor respected this benefited the process. The attitudes of others, and support from management, were reported as facilitators.

• Boundaries - Choosing one’s own supervisor was frequently reported as an important facilitator to effective clinical supervision, as were processes associated with helping people find a supervisor with the ‘right’ qualities. If the purpose of clinical supervision was clearly understood, as were the roles and responsibilities of the supervisee and supervisor, this was beneficial. Alleyne (2007) stated

“professional nature of the supervisory relationship, where boundaries are clearly defined, was recognized by all the participants as an important element in creating a climate where concerns could be freely explored and creative approaches to personal and professional development identified and acted upon”54

• Confidentiality and trust were seen as essential components for effective clinical supervision.

• Individual / personal factors were often reported to be important. A sense of ownership and self-determination to participate actively in the process were reported as key facilitators. Having a sense of collegiality – or ‘team-spirit’ was reported to foster greater trust, and this in turn to facilitate effective team working.

• Knowledge and skills were reported to facilitate effective clinical supervision. Perceiving clinical supervision as an opportunity to learn, and to bring about change and improve care was beneficial. The expertise and knowledge of the supervisor was reported to be important, as was the perception of the quality of the supervision provided.

• Logistics and organisational factors were reported to be key facilitators to effective clinical supervision.

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o Protected time to participate in clinical supervision, with active strategies to support this was a frequently reported facilitator of clinical supervision. Flexibility in the time available from the supervisor was also identified as important.

o The location, and how accessible it was, was important. o Attendance at clinical supervision sessions was facilitated by good administrative

processes ("were given dates, times and venues for 12 months ahead” Abbot 200653), such as the use of a log book. Other studies reported facilitating attendance at CS sessions by sending a letter to all supervisees “introducing the supervisor, listing dates, times and venue for the meetings to take place” 10.

o Planning and organisation to maximise the convenience and clarify the purpose was reported as beneficial.

o Established ground rules were reported to be useful, as was clear guidance on documentation. Ayres (2014) reported the value of developing

“comprehensive guidelines for the supervision of occupational therapy staff set out the service expectations of supervision: a definition, the principles for effective supervision, contract setting, recording, duration and frequency, issues of confidentiality, the content of supervision (including clinical, administrative tasks /management, professional development and training, and support), and the benefits of supervision to both the organization and the individual".55

o The use of a supervision agreement or contract between supervisor and supervisee57 was advocated by some studies. For example, Abbott 2006 reported “the staff involved (supervisors, supervisees and managers) were defined in guidelines that formed part of the clinical supervision policy, and contracts were signed by managers to ensure that staff would have protected time for clinical supervision.

o The mode of delivery was reported as a facilitator, although reports differ in relation to the relative benefits of group or individual supervision.

• Motivation amongst supervisees to participate in clinical supervision and learn from their experiences was reported as a facilitator.

• Session content and structure were reported as facilitator when there was clarity (“Clarity and adherence to the agreed structure and method for working within the group are pivotal" Bailey (2014) 5). Other studies described "useful narratives” that were used to facilitate supervision sessions and the use of a “structure-thinking tool”. This approach – "linking the narratives to nursing research and theory” – enabled participants to “realise that many of the problems they experienced in practice have been discussed in nursing science"7. Brink (2012) also highlighted that “structure creates security and participation”9

‘‘... I realise that the structure is needed as a base for our group sessions because it helps people to think carefully and reflect on important issues ...’’;

‘‘... I think it was good that it was structured and that people had to think before they said anything. It is the structure that helps you express your feelings and what you have been thinking about ...’’

• Terminology – renaming clinical supervision was considered a potential facilitator; “peer support”, “clinical team support” and “professional supervision” were all suggested as alternatives.

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3.2 Barriers and Facilitators reported by supervisors Fewer studies (23/45) documented barriers and facilitators to CS from the perspective of supervisors (see Table 16, Appendix 6)3, 5, 7, 8, 10, 15, 18, 19, 53-55, 57, 59, 64-68, 70, 72, 83, 85-87, 89, 91, 92, 97.

The most commonly identified barriers and facilitators are shown in Figure 6, and briefly described below. Themes, subthemes and data extracted (evidence) is provided in Table 16 (appendix 6).

FIGURE 6. Mindmap of selected barriers and facilitators to clinical supervision as to CS reported by Supervisors. (See Table 16, Appendix 6 for more detail)

We identified three major themes related to the barriers to implementing CS:

• Boundaries (e.g. lack of clarification around roles of supervisors, poor understanding of what CS was and how it differed from line management5, 8, 19, 53, 54, 57, 72, 83, 87, 92, 97

• Knowledge and skills (e.g lack of standardised training and support for supervisors)3, 7, 10, 15,

59, 64-68, 72, 86, 97 • Logistical factors that impacted on the delivery of CS (e.g. location, lack of time, limited

availability of supervisors and supervisees to attend CS)3, 10, 53, 55, 59, 83, 89, 92.

Dawson (2013)83 describes how supervisors commonly report

“confusion as to how CS may differ from line management and mentoring; participants described the effect of this as, ‘blurring and it’s confusing people now’ and that ‘CS seems to be trying to cover all bases – sometimes about line management, but also mentoring, and making sure that the job gets done appropriately’”

The need for standardised education and training for supervisors was a common theme. As Milne (2010)68 points out that the “supervisor training paradox” is the result of

“a lack of suitable training for supervisors” arguing that “supervision is still being practiced incompetently”.

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Interestingly supervisors were less concerned by personal factors such as motivation, confidentiality and choice83 compared with supervisees.

Several studies reported implementing novel approaches to overcome many of these challenges. For example Chilvers (2009)10 developed an essentials and desirable list for a person specification for supervisors delivering CS and Wallbank (2012a,b) developed a Knowledge, Skills and Competency framework for supervisors and supervisees to enhance the clarity around roles and responsibilities72,

74.

3.3 Barriers and Facilitators to clinical supervision as reported at health system level Our review identified 11 studies that reported barriers and facilitators to CS implementation at the level of the health system (see Table 17, Appendix 7). These typically fell into one of three categories:

• Accessibility of care (e.g. lack of adequate space for CS sessions, lack of time provision)5, 55 • Human resources (e.g. a burden on human resources, under-resourcing, failure to employ

staff to backfill positions)53, 85 • Financial resources (e.g. lack of a viable business plan, cost of training and employing

outside facilitators)3, 55, 85

These challenges to CS implementation are clearly illustrated in the following quote from Lynch (2008):

“Senior management, which included a number of senior nurses in the mental health programme, was concerned about the serious human resource issues such as: an increase in work cover and sick leave, and difficulties with recruitment and retention. In addition to the above human resource data, they also conducted a needs analysis via qualitative surveys and focus groups in two teams; the results of which highlighted a sense of dissatisfaction with work loads, team dynamics, and management. The culture and environment in this organization were described by one participant as: . . . angry, hostile . . . demoralized and anti-management. Another participant stated that in general staff felt: . . . unsupported . . . There weren’t systems in place to keep them safe”.

The cumulative lack of resourcing (human and financial) and poor organisational planning negatively impacting on front-line staff and their views of CS as described in White and Winstanley (2010)

“In the absence of making appropriate logistical arrangements, the perfunctory introduction of CS was regarded as an additional activity for staff to accommodate. This was reported to stretch human resources to breaking point and created predictable inter-staff tensions”

Some studies however viewed the funding implications of CS as opportunity or as an “investment”. Chilvers (2009)10 highlighted the key benefits of CS and pointed out that CS

“can result in an impact on staff turnover and risk management with obvious economic benefits to the organization”

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3.4 Barriers and Facilitators to clinical supervision reported by social and political level Few studies actually reported any barriers or facilitators at the social and political level (n=8). These are detailed in Table 18 (Appendix 8).

Four studies reported barriers to implementation of CS due to ‘organisational restructuring’ against the backdrop of a changing political landscape53, 64-67 and the absence of a national policy for CS64-67. Abbott (2006) highlighted the negative impact that organisational restructuring created regarding on CS implementation citing concerns that

“clinical supervision might be allowed to lapse, given the departure of some trained supervisors… and a proposed organizational re-structuring” 53.

Four studies highlighted the importance of CS and describing CS as being of “critical importance and a mandatory requirement” 5, 56 (Table 18). These studies report the endorsement of CS in multiple national guidelines that have been published over the last 20 years (e.g. Department of Health, 1993; UKCC, 1996; UKCC 2001), which has facilitated and promoted the use of CS. Furthermore the widespread adoption of CS is now a “legal and professional requirement” for many professional groups (e.g. College of Occupational Therapists, Chartered Society of Physiotherapy) which also promotes this view55.

DISCUSSION AND CONCLUSIONS This review has identified a number of factors that may impact on the implementation of CS at the level of the supervisee, supervisor, health system and wider social and political levels. Consideration of these may aid the planning of an effective clinical supervision intervention.

The most commonly reported barriers and facilitators related to logistical and organization factors associated with clinical supervision. A number of innovative practical approaches to logistical dilemmas that facilitated the implementation of clinical supervision were identified within this review. Key logistical/organization points to consider when planning a clinical supervision appear to include:

• Time available to supervisees and supervisors. Protected time • Administrative processes to support effective, efficient planning and organization. • Clarity around requirements for documentation; consider ground rules and supervisory

contracts? • Accessible venue.

Boundaries associated with the clinical supervision process also contributed to a large number of reported barriers, and facilitators. Key points to consider would include:

• Clarity around roles and responsibilities of supervisees and supervisors • Whether supervisees can choose a supervisor, and how to facilitate this effectively

Further commonly reported barriers/facilitators that should be considered include:

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• Session content and structure. There is no clear consensus on the best content and structure, but clarity of content and structure appears important. Descriptions of content and structure of clinical supervision interventions were synthesized in Synthesis 1.

• Knowledge and skills of the supervisor is perceived important by supervisees, and standardized training and support is considered beneficial by supervisors.

• Confidentiality and trust. To support effective clinical supervision it is reported that supervisees must trust that what they discuss within sessions remains confidential.

• Terminology. The term “clinical supervision” is frequently reported as a barrier to an effective process, and may be associated with negative attitudes and culture, resistance to change and lack of motivation in relation to the supervisory process. An alternative term may facilitate a more positive attitude, and increased motivation for active participation.

There were fewer barriers identified at higher organisational levels, however this may simply be a reflection of the small number of papers published in this area.

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44. Fitzpatrick S, Smith M, Wilding C. Quality allied health clinical supervision policy in Australia: a literature review. Australian health review : a publication of the Australian Hospital Association. 2012;36(4):461-465. 45. Kleiser H, Cox DL. The Integration of Clinical and Managerial Supervision: a Critical Literature Review. BRITISH JOURNAL OF OCCUPATIONAL THERAPY. 2008;71(1):2. 46. Pearce P, Phillips B, Dawson M, Leggat SG. Content of clinical supervision sessions for nurses and allied health professionals: A systematic review. Clinical Governance. 2013;18(2):139-154. 47. Butterworth T, Bell L, Jackson C, Pajnkihar M. Wicked spell or magic bullet? A review of the clinical supervision literature 2001-2007. Nurse Education Today. 2008;28(3):264-272. 48. Buus N, Gonge H. Empirical studies of clinical supervision in psychiatric nursing: a systematic literature review and methodological critique. International Journal of Mental Health Nursing. 2009;18(4):250-264. 49. Dawson M, Phillips B, Leggat S. Clinical supervision for allied health professionals: A systematic review. Journal of Allied Health. Sum 2013 2013;42(2):65-73. 50. Dilworth S, Higgins I, Parker V, Kelly B, Turner J. Finding a way forward: a literature review on the current debates around clinical supervision. Contemporary nurse. 2013;45(1):22-32. 51. Francke AL, de Graaff FM. The effects of group supervision of nurses: A systematic literature review. International Journal of Nursing Studies. 2012;49(9):1165-1179. 52. Ducat WH, Kumar S. A systematic review of professional supervision experiences and effects for allied health practitioners working in non-metropolitan health care settings. J Multidiscip Healthc. 2015;8:397-407. 53. Abbott S, Dawson L, Hutt J, Johnson B, Sealy A. Introducing clinical supervision for community-based nurses. British Journal Of Community Nursing. 2006;11(8):346-348. 54. Alleyne J, Jumaa MO. Building the capacity for evidence-based clinical nursing leadership: The role of executive co-coaching and group clinical supervision for quality patient services. Journal of Nursing Management. 2007;15(2):230-243. 55. Ayres J. Quality and effectiveness of clinical supervision : evaluation of an occupational therapy service. British Journal of Occupational Therapy. 2014. 56. Cerinus M. The role of relationships in effective clinical supervision. Nursing Times. 2005;101(14):34-37. 57. Cookson J, Sloan G, Dafters R, Jahoda A. Provision of clinical supervision for staff working in mental health services. Mental Health Practice. 2014;17(7):29-34. 58. Cox DL, Araoz G. The experience of therapy supervision within a UK multi-centre randomized controlled trial. Learning in Health and Social Care. 2009;8(4):301-314. 59. Davis C, Burke L. 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;20(6):782-793. 60. Deery R. An action-research study exploring midwives' support needs and the affect of group clinical supervision. Midwifery. 2005;21(2):161-176. 61. Jarrett P. Clinical supervision in the provision of intensive home visiting by health visitors. Community Practitioner. 2014. 62. Kenny A, Allenby A. Implementing clinical supervision for Australian rural nurses. Nurse Education In Practice. 2013;13(3):165-169. 63. Koivu A, Saarinen PI, Hyrkas K. Who benefits from clinical supervision and how? The association between clinical supervision and the work‐related well‐being of female hospital nurses. Journal of Clinical Nursing. 2012;21(17-18):2567-2578. 64. Lynch L, Happell B. Implementing clinical supervision: Part 1: laying the ground work. International Journal Of Mental Health Nursing. 2008;17(1):57-64. 65. Lynch L, Happell B. Implementation of clinical supervision in action: part 3: the development of a model. International Journal of Mental Health Nursing. 2008;17(1):73-82. 66. Lynch L, Happell B. Implementation of clinical supervision in action: Part 2: Implementation and beyond. International Journal of Mental Health Nursing. 2008;17(1):65-72. 67. Lynch L, Happell B, Sharrock J, Cross W. Implementing clinical supervision for psychiatric nurses -- the importance of education. International Journal of Psychiatric Nursing Research. 2008;14(1):1785-1796.

34

68. Milne D. Can we enhance the training of clinical supervisors? A national pilot study of an evidence-based approach. Clinical psychology & psychotherapy. Vol 17; 2010: 321-328. 69. Taylor E, Austin K, Gibb J. Clinical supervision in a remote island setting. Mental Health Practice. 2009;12(10):16-19. 70. Hill A, Turner J. Implementing clinical supervision (part 3): an evaluation of a clinical supervisor's recovery-based resource and support package. Mental Health Nursing. 2011;31(5):16-20. 71. Wallbank S. Maintaining professional resilience through group restorative supervision. Community Practitioner: The Journal Of The Community Practitioners' & Health Visitors' Association. 2013;86(8):26-28. 72. Wallbank S. Health visitors' needs--national perspectives from the Restorative Clinical Supervision Programme. Community Practitioner: The Journal Of The Community Practitioners' & Health Visitors' Association. 2012;85(4):29-32. 73. Wallbank S. Reducing burnout and stress: the effectiveness of clinical supervision. Community Practitioner. 2011;84(7). 74. Wallbank S, Woods G. A healthier health visiting workforce: findings from the restorative supervision programme. Community Practitioner: The Journal Of The Community Practitioners' & Health Visitors' Association. 2012;85(11):20-23. 75. White J. A model of child protection supervision for school health practitioners. Community Practitioner. 2008;81(5):23-27. 76. Erratum... White E, Winstanley J. Implementation of clinical supervision: educational preparation and subsequent diary accounts of the practicalities involved, from an Australian mental health nursing innovation. Journal of Psychiatric and Mental Health Nursing 2009;16:895-903. Journal of Psychiatric & Mental Health Nursing. 2010;17(1):96-96. 77. White E, Winstanley J. Implementation of Clinical Supervision: educational preparation and subsequent diary accounts of the practicalities involved, from an Australian mental health [corrected] nursing innovation. Journal of psychiatric and mental health nursing. Vol 16; 2009: 895-903. 78. White E, Winstanley J. Does clinical supervision lead to better patient outcomes in mental health nursing? Nursing times. Vol 106; 2010: 16-18. 79. White E, Winstanley J. Clinical supervision: outsider reports of a research-driven implementation programme in Queensland, Australia [ACTRN12611000726954]. Journal of nursing management. Vol 18; 2010: 689-696. 80. White E, Winstanley J. Clinical supervision for nurses working in mental health settings in Queensland, Australia: A randomised controlled trial in progress and emergent challenges [[ACTRN12611000726954]]. Journal of research in nursing. Vol 14; 2009: 263-276. 81. White E, Winstanley J. Quality of care and patient outcomes: a randomised controlled trial of Clinical Supervision in Queensland, Australia. Final Report Brisbane, Australia:Queensland Treasury/Golden Casket Foundation [available from Osman Consulting Pty Ltd; osmanconsulting@ozemail,com.au] [ACTRN12611000726954]. 2009. 82. Best D, White E, Cameron J, et al. A model for predicting clinician satisfaction with clinical supervision. Alcoholism Treatment Quarterly. 2014;32(1):67-78. 83. Dawson M, Phillips B, Leggat SG. Effective clinical supervision for regional allied health professionals: the supervisor's perspective. Australian Health Review: A Publication Of The Australian Hospital Association. 2013;37(2):262-267. 84. Dawson M, Phillips B, Leggat SG. Effective clinical supervision for regional allied health professionals - the supervisee's perspective. Australian Health Review: A Publication Of The Australian Hospital Association. 2012;36(1):92-97. 85. Rice F, Cullen P, McKenna H, Kelly B, Keeney S, Richey R. Clinical supervision for mental health nurses in Northern Ireland: Formulating best practice guidelines. Journal of Psychiatric and Mental Health Nursing. 2007;14(5):516-521. 86. Herbert JT, Trusty J. Clinical supervision practices and satisfaction within the public vocational rehabilitation program. Rehabilitation Counseling Bulletin. 2006 Winter 2006;49(2):66. 87. Cutcliffe JR, Hyrkas K. Multidisciplinary attitudinal positions regarding clinical supervision: a cross-sectional study. Journal of nursing management. 2006;14(8):617-627.

35

88. Hall T, Cox D. Clinical supervision: An appropriate term for physiotherapists? Learning in Health and Social Care. 2009;8(4):282-291. 89. McKenna B, Thom K, Howard F, Williams V. In search of a national approach to professional supervision for mental health and addiction nurses: The New Zealand experience. Contemporary Nurse. 2010;34(2):267-276. 90. Carney S. Clinical supervision in a challenging behaviour unit. Nursing Times. 2005;101(47):32-34. 91. Long CG, Harding S, Payne K, Collins L. Nursing and health‐care assistant experience of supervision in a medium secure psychiatric service for women: Implications for service development. Journal of Psychiatric and Mental Health Nursing. 2014;21(2):154-162. 92. Boland N, Strong J, Gibson L. Professional supervision in the work rehabilitation arena in one Australian State. Work: Journal of Prevention, Assessment & Rehabilitation. 2010;37(2):155-165. 93. Kuipers P, Pager S, Bell K, Hall F, Kendall M. Do structured arrangements for multidisciplinary peer group supervision make a difference for allied health professional outcomes? Journal Of Multidisciplinary Healthcare. 2013;6:391-397. 94. Edwards D. Clinical supervision and burnout: the influence of clinical supervision for community mental health nurses. Journal of Clinical Nursing. 2006;15(8). 95. Edwards D, Cooper L, Burnard P, et al. Factors influencing the effectiveness of clinical supervision. Journal of psychiatric and mental health nursing. 2005;12(4):405-414. 96. Buus N. Psychiatric nursing staff members' reflections on participating in group-based clinical supervision: A semistructured interview study. International Journal of Mental Health Nursing. 2011;20(2). 97. Wallbank S. A healthier health visiting workforce : findings from the Restorative Supervision Programme. Community Practitioner. 2012. 98. Brunero S, Stein-Parbury J. The effectiveness of clinical supervision in nursing: an evidenced based literature review. Australian Journal of Advanced Nursing. 2008;25(3):86-94. 99. Buus N. Empirical studies of clinical supervision in psychiatric nursing: A systematic literature review and methodological critique. International Journal of Mental Health Nursing. 2009;18(4). 100. Fitzpatrick S, Smith M, Wilding C. Quality allied health clinical supervision policy in Australia: a literature review. Australian Health Review: A Publication Of The Australian Hospital Association. 2012;36(4):461-465. 101. Kleiser H, Cox DL. The integration of clinical and managerial supervision: A critical literature review. The British Journal of Occupational Therapy. 2008;71(1):2-12. 102. Pearce P, Phillips B, Dawson M. Content of clinical supervision sessions for nurses and allied health professionals : a systematic review. Clinical Governance. 2013;18(2):139-154. 103. Review of Basic counseling skills. Journal of the Indian Academy of Applied Psychology. 2014;40(1):157-157. 104. O'Connell B, Dowling M. Community psychiatric nurses' experiences of caring for clients with borderline personality disorder. Mental Health Practice. 2013;17(4):27-33. 105. Turner K, Laut S, Kempster J, Nolan S, Ross E, Edmonds E. Group clinical supervision: supporting neurology clinical nurse specialists in practice. Journal of Community Nursing. 2005;19(9):4. 106. Edwards D, Burnard P, Hannigan B, et al. Factors influencing the effectiveness of clinical supervision [corrected] [published erratum appears in J PSYCHIATR MENT HEALTH NURS 2005 Dec;12(6):752]. Journal of Psychiatric & Mental Health Nursing. 2005;12(4):405-414. 107. Cutcliffe JR, Hyrkäs K. Multidisciplinary attitudinal positions regarding clinical supervision: a cross-sectional study. Journal Of Nursing Management. 2006;14(8):617-627. 108. Turner J, Hill A. Implementing clinical supervision (part 2): using Proctor’s model to structure the implementation of clinical supervision in a ward setting.

. Mental Health Nursing. 2011;31(4):14-19. 109. Gonge H. Model for investigating the benefits of clinical supervision in psychiatric nursing: A survey study. International Journal of Mental Health Nursing. 2011;20(2). 110. Burns T, Rugkåsa J, Molodynski A, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet (London, England). Vol 381; 2013: 1627-1633.

36

APPENDIX 1: Small work group members for preliminary scoping work & protocol development

Ann Holmes, CNOD

Dr Graham Sloan, Ayrshire & Arran Primary Care Trust

Prof Ruth Deery, University of West of Scotland

Prof Jean Rankin, University of West of Scotland

Dr Mick Fleming, University of West of Scotland

Prof Helen Cheyne, NMAHP RU

Dr Pauline Campbell, NMAHP RU

Dr Alex Pollock, NMAHP RU

37

APPENDIX 2: Expert critique of Calvert 2014, provided by Working Group members (Prof Ruth Deery and Dr Mick Fleming)

Calvert, I. (2014) Support for midwives – A model of professional supervision based on the recertification programme for midwives in New Zealand, Women and Birth, Vol. 27, pp. 145-150.

This paper has been a useful read if only to help clarify and re-focus the nature of supervision in the health professions, in this case midwifery. I don’t think we can ignore it but I do feel slightly uncomfortable about its inclusion when we have rejected others. It is the latter part of the paper that is convincing for inclusion.

My unease rests with the fact that it reports a New Zealand perspective although the author does refer to literature in the UK. Neither does the paper report an empirical study and there is no data relating to the evaluation of clinical supervision (synthesis 2) or the barriers and facilitators to implementation of clinical supervision. The model referred to in the paper (Proctor) is not evidence based. The publication does consider the political and cultural context for recertification of midwives in New Zealand and we liked the term professional supervision as opposed to clinical supervision. Using the term ‘professional supervision’ in our context may help to overcome any barriers to clinical supervision in the taskforce group. Within the analysis of trends from the literature reviewed, Calvert acknowledges the risks inherent in the practice of midwives and the physiological and psychological impact of being exposed to clinical practice that involves exposure to threatening and traumatic events.

The processes and mechanisms of professional supervision are defined in benevolent terms and professional supervision is then considered within the context of the safe practice and regulation of midwives, in particular the requirements for the recertification of midwives. In our case this would link to NMC revalidation.

The publication then makes clear distinctions between firstly, management or supervision designed for surveillance and secondly, clinical supervision. Within the discussion of these distinctly different typologies of supervision the relevance of professional supervision in facilitating support, time for reflection on clinical practice and professional development is made clear. The relevance of professional supervision to the process of recertification emerges clearly from the end of page 146-147.

The remainder of the publication is focused on an overview of the specific aspects (managerial /normative, educative/formative and supportive/restorative functions and the reflection on practice) of the professional supervision model and how these aspects relate to the process of recertification. It is this section that provides the explicit detail about the professional supervision intervention. The detail in this section is informative and the detail and its relevance to recertification and regulation (not dissimilar to present UK policy for midwives and registered nurses) supports the rationale for the inclusion of this paper in the review.

APPENDIX 3: RECERTIFICATIO

N PRO

GRAMM

E SUM

MARY AN

D PLANN

ER (Midw

ifery Council of New

Zealand, January 2015)

Your portfolio is your collection point for Recertification evidence. It should include reflections about how research or learning has

been incorporated into your practice

1 April 2015 to 31 M

arch 2016 1 April 2016 to 31 M

arch 2017 1 April 2017 to 31 M

arch 2018 1 April 2018 to 31 M

arch 2019 CO

MPU

LSORY EDU

CATION

Com

bined Emergency Skills day

(Annual – in 2014, due 12 months from

when

MR/N

NR w

as completed in 2013)

Midw

ifery Practice Day (O

nce every three years - due 3 years from last

TSW Practice Day

Breastfeeding Workshop

(Half day, once every three years)

Breastfeeding activity (O

nce every three years)

Midw

ifery Standards Review

(Once every tw

o years) M

SR Panels have discretion to change this requirem

ent. New

graduates are reviewed at the

end of their first year

PRACTICE ACROSS THE M

IDWIFERY SCO

PE Antenatal, Intrapartum

, Postnatal A

I P

A I

P A

I P

A I

P ELECTIVE EDU

CATION

In each 3 year period, 5 points per year, totalling a m

inimum

of 15 points over 3 years Courses attended &

points: Courses attended &

points: Courses attended &

points: Courses attended &

points:

PROFESSIO

NAL ACTIVITES

In each 3 year period, 5 points per year, totalling a m

inimum

of 15 points over 3 years Activity &

points: Activity &

points: Activity &

points: Activity &

points:

(Reproduced from: https://w

ww

.midw

iferycouncil.health.nz/images/stories/pdf/Education-Prereg/Recertification_Planner_revisedJan15.pdf , accessed

24th Septem

ber 2015).

39 APPEN

DIX 4: Table 14: Summ

ary of characteristics of systematic review

s of effectiveness of clinical supervision interventions

Authors Year

Title of review

paper Stated aim

Included studies

Data presented Conclusions (quote from

paper) Judgem

ent of risk of bias

Brunero 2008

98 The effectiveness of clinical supervision in nursing: an evidenced based literature review

The purpose of this paper is to review

selected research studies that have focused on evaluating the effectiveness of CS in nursing.

22 studies - 4 "com

parative", 3 "pre-post" evaluation studies; 15 "post-only" evaluation studies

Description of CS (including summ

ary of frequency etc), com

parison intervention, and statem

ent of focus of study. O

utcomes relating to

Norm

ative, Formative &

Restorative function w

ere stated. It is unclear w

hether these data are effectiveness data. N

o numerical data extracted

from studies (other than participant

numbers).

There is research evidence to suggest that CS provides peer support and stress relief for nurses (restorative function) as w

ell a means of

promoting professional accountability (norm

ative function) and skill and know

ledge development (form

ative function).

HIGH

Butterworth

200847

"Wicked spell or

magic bullet? A

review of the

92 studies

Under them

es of: (i) levels of engagem

ent; (ii) the usefulness of clinical supervision as an educational and supportive device; (iii) ethical debate, personal and organisational challenges; (iv) effects on patient outcom

e and staffing disposition.

Levels of engagement carry a num

ber of confounding factors. They are likely to be determ

ined by organisational culture, availability of tim

e, supervisor numbers and a host of other local factors. Few

significant conclusions can be draw

n from the reported data but

organisational culture is consistently reported as an important

determinant of im

plementation. Clinical supervision as a supportive

device has attracted more attention than any other. M

ost studies are self-reported, qualitative in m

ethod and suggest that clinical supervision and its processes confer benefit in m

any ways. It is not

possible to attribute all these positive effects merely to clinical

supervision. However, it is quite proper to suggest that structured

opportunities to discuss case related practice, personal and educational developm

ent are vital to nurses, their practice and patient safety.

HIGH

Buus 2009

99 Em

pirical studies of clinical supervision in psychiatric nursing: A system

atic literature review

and m

ethodological critique

The aim of the follow

ing system

atic literature review

was to sum

marize and

critically evaluate all em

pirical studies of clinical supervision in psychiatric nursing and to identify and discuss issues that w

ould benefit from

additional research in the future.

34 papers, reported from

25 em

pirical projects. These w

ere 9 "effect" studies, 12 "survey" studies, 6 "interview

" studies, 7 "case studies"

Aim, design, m

ethods/instruments,

settings & participants, analyses,

description of supervision, result, lim

itations

The reported findings from the four projects designed to m

easure the effect of clinical supervision did not provide convincing em

pirical evidence to support the assum

ption that clinical supervision in psychiatric nursing settings had an effect on the nurses and/or the patients in their care (see Table 1).

LOW

Dawson,

201349

Clinical Supervision for Allied Health Professionals: A System

atic Review

A current systematic review

of the evidence for CS for AHPs w

as conducted to answ

er the review

questions: what is CS?, w

hy

33 papers; 8 system

atic review

s, 2 com

parison &

quasi-

Table summ

arising systematic review

s. Tables of studies - aim

, setting &

participants, results, limitations

The current review identified a significant gap in CS research for

AHPs. Those studies that included AHPs did so in small num

bers or had inadequately developed research m

ethods. The current review

was not able to identify a com

mon definition of CS, and m

any of the studies did not offer a definition of CS. There is, how

ever, much less

LOW

40

Authors Year

Title of review

paper Stated aim

Included studies

Data presented Conclusions (quote from

paper) Judgem

ent of risk of bias

do AHPs have CS?, and what

are the processes and outcom

es of CS? Due to the paucity of allied health CS literature, the review

needed to consider em

pirical studies from

other health professional groups.

experimental

studies; 12 cross-sectional studies; 9 interview

studies

clarity about how CS should be provided as there are conflicting

positions on the inclusion of normative and restorative functions.3,9

The form of CS varied across the studies and included 1:1, group, or

peer supervision. The 1:1 and group forms w

ere most com

monly

reported, however there w

as no evidence to suggest that one CS form

was superior. The scope of CS also varied, w

ith sessions occurring fortnightly to m

onthly, lasting from 45 m

inutes up to 2 hours; again there w

as no evidence for the best approach. Dilw

orth, 2013

50 Finding a w

ay forw

ard: A literature review

on the current debates around clinical supervision

The purpose of the review

was to scope the current

field, identify the main

debates and existing evidence around clinical supervision w

ith a view

to develop an understanding of current practices that w

ill inform

a larger project (Dixon-W

oods, Cavers, et al., 2006; M

ays, Pope, & Popay,

2005).

59 studies Presents a "critical interpretive approach" to the CS literature.

There are a plethora of clinical supervision models w

ithin the nursing literature but few

of them are w

ell defined (Buus & Gonge, 2009;

Fowler, 1996; Sloan, W

hite, & Coit, 2000). Proctor’s m

odel is becom

ing widely utilised w

ithin the nursing research. Despite its increasing popularity, there is criticism

that perhaps this model is too

imprecise, failing to identify interventions appropriate to each

domain (Sloan et al., 2000). The lack of clarity about role and

structure has led to a large body of evidence that is diffuse. As a result it lacks strength in the claim

s it makes for clinical supervision.

All of the reviews appear to reach a sim

ilar conclusion: the evidence that clinical supervision is effective is not strong and there is a need to address m

ethodological limitations in order to im

prove the strength of the evidence. Despite m

ethodological limitations, and

resistance from health professionals and organisations there is an

argument for positive changes in w

ork satisfaction, decreases stress, burnout nurses w

ellbeing and effective clinical supervision (Dawson,

Phillips, & Leggat, 2012; Edw

ards et al., 2006; Hyrkäs et al., 2006; Koivu, Saarinen, &

Hyrkas, 2012; Severinsson & Kam

aker, 1999; W

allbank & Hatton, 2011). There is also som

e evidence that clinical supervision can im

prove patient and staff satisfaction (White &

W

instanley, 2010); enhance education, expand scope of practice (M

annix et al., 2006; Moorey et al., 2009) and provide a forum

for critical reflective practice (Cleary &

Freeman, 2005; Cross et al., 2010;

Hyrkäs et al., 2002; Kilcullen, 2007).

LOW

Ducat 2015

52 A system

atic review

of professional supervision experiences and effects of allied health practitioners w

orking in non-m

etropolitan

The aim of this

comprehensive system

atic review

was to synthesize the

current evidence base for both the experience and effects of professional supervision for allied health professionals w

orking in non-m

etropolitan health settings. Specifically, the

5 studies included - 2 qual studies; 2 cross-sectional quant; 1 pre-post quant

Design, participants, sample, key

findings, limitations, quality appraisal

Considering the large pool of studies retrieved for further investigation, few

of these met inclusion criteria dem

onstrating the paucity of prim

ary research in this area. Increased training, policies, and im

plementation fram

eworks to ensure the definition and

functions of supervision are agreed upon across the allied health disciplines in non-m

etropolitan areas are needed. Furthermore,

systematic evaluation of supervision im

plementation in non-

metropolitan settings, investigation of the experience and effects of

distance based supervision (versus face-to-face), and increased rigor in research studies investigating non-m

etropolitan allied health

LOW

41

Authors Year

Title of review

paper Stated aim

Included studies

Data presented Conclusions (quote from

paper) Judgem

ent of risk of bias

health care settings

review questions w

ere: 1. W

hat are the experiences of professional supervision for allied health professionals w

orking in non-m

etropolitan settings? 2. W

hat are the effects of professional supervision on allied health practitioner practice and client outcom

es in non-m

etropolitan locations?

profession supervision is needed.

Fitzpatrick 2012

100 Q

uality allied health clinical supervision policy in Australia: a literature review

Not stated

n=25 N

arrative By gaining an understanding of w

hat high quality clinical supervision is and how

it is best put into practice, it is anticipated that this will

form the first step in developing an

understandable and useful universal supervision policy for all allied health professionals.

HIGH

Francke 2012

51 The effects of group supervision of nurses: A system

atic literature review

Review questions

1. What are the effects of

group supervision of nurses on nurse and patient outcom

es? 2. W

hat are the characteristics of the group supervision program

mes in

relevant studies? 3. W

hat are the m

ethodological quality and characteristics of relevant studies?

17 studies: 8 controlled studies, 9 pre-post test design studies (no RCTs)

characteristics of group supervision (including topics discussed, process, period &

duration); study quality, sam

ple, variables/instruments, analysis,

results (narrative)

All studies indicated that group supervision produced to a greater or lesser extent certain positive effects. How

ever, the outcome variables

varied and not all studies pointed in the same direction. For instance,

some publications indicated that em

otional exhaustion decreased in supervised nurses (e.g. Butterw

orth et al., 1998, 1999), whilst others

did not find significant effects on burnout or emotional exhaustion at

all (Berg et al., 1994HQ; Hallberg, 1994; Palsson et al., 1996). At the

mom

ent the nursing profession has more than tw

o decades profound experiences w

ith clinical group supervision for nurses. However, this

systematic review

provides the same overall conclusion as tw

o review

s performed at the end of the previous century (Hyrkas et al.,

1999; William

son and Dodds, 1999), namely that the em

pirical evidence is still lim

ited.

LOW

Kleiser 2008

101 The integration of clinical and m

anagerial supervision: a critical literature review

The aim of this study w

as to review

and evaluate the existing evidence in order to establish if the collaboration of clinical and m

anagerial supervision can be sustained effectively. If so, then the governm

ent’s new appraisal

system (KSF, DH 2004) m

ay offer structure and guidance w

ithin the process. The research question, therefore,

25 studies; 16 w

ith SIGN level

of evidence of 3 or m

ore; 9 were

'expert opinion'

SIGN level/grade of evidence and

authors conclusions This review

did not find any evidence to support the co-alliance of supervision and appraisal.

HIGH

42

Authors Year

Title of review

paper Stated aim

Included studies

Data presented Conclusions (quote from

paper) Judgem

ent of risk of bias

was ‘Should supervision be

used as a tool for monitoring

competency in clinical

practice? Pearce 2013

102 Content of clinical supervision sessions for nurses and allied health professionals: A system

atic review

The aim of this system

atic review

was to evaluate the

current evidence regarding the content of clinical supervision for nursing and allied health professionals.

n=20: 9 cross-sectional studies; 2 literature review

s; 9 opinion pieces

Aim, participants &

intervention, data collection, them

es identified, lim

itations

The findings of this systematic review

demonstrated that there is

scarce current evidence for what content is included in clinical

supervision for health professionals. None of the published articles

included in this review explicitly addressed the question of content of

clinical supervision and there were m

ethodological issues with m

any of the studies. This system

atic review extrapolated som

e recurring them

es related to the content of clinical supervision for the nursing, allied health and m

edical professions from the current literature.

HIGH

APPENDIX 5: Table 15: Sum

mary of barriers and facilitators to clinical supervision as reported by supervisees

Main them

e Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Attitude/ Culture

Long 2014

91 Acceptability

"Acceptance of the goals of supervision does not necessarily lead to an effective programm

e of CS. Indeed, the U

KCC report on nursing in secure environments (U

KCC and University of Central

Lancashire 1999) noted: (1) the low level of acceptance of CS because of practical

implem

entation problems and lack of m

anagement support, and (2) the low

level of availability of CS for nurses w

ho work in conditions that test professional resilience"

Gonge 2010

24 Attitude

"Objective characteristics of nursing staff m

embers, such as qualifications, length of experience,

and previous experience with clinical supervision m

ay contribute to different attitudes toward

engaging themselves in the reflective process essential to clinical supervision”

Lynch 2008 64-67

Culture "Culture of the nursing profession has not traditionally em

bodied clinical supervision as an essential part of professional"

White

and W

instanley (2009 &

2010) 23,

77-81

Longevity of CS

“Predictions about the longevity of the implem

entation of CS became a proxy indicator of the

extent to which the organization w

as likely to inculcate CS into the prevailing culture”. “I know

I keep on saying this, but education on the supervision process is so important. As w

e now

have managers stating supervision is som

ething that should be imposed onto nurses in their

units, as they (nurses) need it. I do not agree with this process, because if supervision is seen as a

process that is imposed by m

anagement nurses w

ill not participate in supervision. (12M12)”

White

and W

instanley (2009 &

2010) 23,

77-81

Managerial

support

“Overw

helmingly, the trainees reported that the m

ost helpful factors they found in helping them

to establish CS arrangements at local level w

as the demonstrable

support from their N

urse Unit M

anager (NU

M), regular contact w

ith their respective area coordinator and the em

ergent enthusiasm and cohesion of

participating supervisees”. “Continued com

mitm

ent from N

UM

’s, nurse manager and nursing director for

ward backfill and the com

mitm

ent from the staff attending the sessions. Staff

flexibility. Eagerness for supervision. Block booking a room in advance. Having our

clinical supervision roster so that, when one of us is on holidays, w

e know the other

person’s sessions, so we can relieve. Everything is going really w

ell. Staff remains

enthusiastic. Supervisors love what they are doing! (20M

4)”

44 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

“Similar faces com

ing, which is creating an arena for openness and m

ore honest discussion. The groups appear to be form

ing better and more serious issues are

coming to the surface. N

UM

’s are beginning to quarantine time for staff, so less

interruptions to sessions. Some staff are spreading the new

s about the benefits of supervision, and continued education throughout the cam

pus (including to NU

M’s)

keeps it in people’s minds. (13M

9)”

Davis 2012

59 N

egative attitude

“Johns (2003) undertook a study to evaluate the effect of clinical supervision on leadership. He found that w

ard managers lacked vision and expressed difficulty in m

aintaining clinical credibility. Difficulty in facilitating their staff into accepting role responsibility w

as expressed. Innovations w

ere not introduced or implem

ented for fear of conflict and there was a culture of

conflict avoidance. Clinical supervision proved to have limited effect in developing

transformational leaders for w

hich Johns (2003) lists a number of factors including an

unsympathetic organisational culture. W

ard managers brought m

ainly negative events to clinical supervision sessions, echoing early w

ork of Maggs and Biley (2000) w

ho report that nurses find it easier to highlight things that w

ent badly and harder to identify those that go well”.

Cross 2010

11 N

egative attitudes

"..sharing emotions, w

ariness of ‘navel gazing’ and self-examination"

Deery 2005

60 N

egative attitudes

"Supervision of midw

ives being viewed by som

e midw

ives as an imposition on their practice and

a policing mechanism

". “it w

as like well w

hat’s the point of it [clinical supervision], we just haven’t got tim

e for it and yet I suppose if there w

as ever a time w

e needed it, it was at that tim

e. (Interview 5)"

Jarrett 2014

61 N

egative attitudes

"Practitioners' perceptions of clinical supervision are often negative and supervision is seen as being about 'doing w

rong' or about 'not coping' rather than an opportunity for support, reflection and developm

ent”

Lynch 2008

64-67 N

egative attitudes

“… people of course w

ere suspicious that it was ‘snoopervision’, suspicious about having clinical

supervision with som

eone who they actually knew

, suspicious about having clinical supervision w

ith people who they saw

as their seniors, having clinical supervision with people they had not

seen in clinical practice for a long time”. Also as a result of restructuring, staff w

ere "level of paranoia/suspiciousness tow

ards managem

ent and issues of proving that managem

ent and the organization could sustain the im

plementation of clinical supervision. The findings indicated that

nurses in this organization were cynical and pessim

istic about anything senior managem

ent tried to im

plement and they had little or no faith in their ability to sustain anything . . . w

e have a very paranoid w

orkforce . . . and the people at the time w

ith the loudest voices were probably the

most paranoid . . . about 80%

were really resistant to clinical supervision or to anything w

e have tried to im

plement…

.”

45 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Davis 2012

59 N

egative outcom

es

“Negative com

ments included tim

e constraints, fears of a breech in confidentiality and anxiety about experiencing uncom

fortable feelings such as embarrassm

ent, fear of exposure, intim

idation and inadequacy. Negative outcom

es, suspicion and resistance are among the issues

comm

only identified as barriers to involvement in or im

plementation of clinical supervision”.

Abbott 2006

53

Negative

supervision culture

"Some tendencies to m

oan for moaning’s sake, and a few

longer-serving mem

bers of staff rem

ained cynical (‘we’ve seen it all before’)".

Ayres 2014

55

Negative

supervision culture

"Supervisors and supervisees perceived supervision to be a relatively unproductive experience"

Bailey 2014

5

Negative

supervision culture

“Power and com

petition dynamics”

"Purposefully exposing power and com

petition issues; reflecting on rejected com

ments and ideas; focusing on the collective endeavour and its significance and

developing conscious connections among the group participants"

Brink 2012

9

Negative

supervision culture

"Supervision situation as stressful and able to provoke anxiety…also experienced a reluctance to

declare personal values to a larger group of people”

Buus 2013

4

Negative

supervision culture

"Some of the inertia and resistance w

e experienced were closely related to the participants’

previous experiences with supervision and to the interpersonal relationships betw

een the participants"

White

and W

instanley (2009 &

2010) 23,

77-81

Negative

supervision culture

“I am feeling less m

otivated about the Trial, as those around me are losing interest; e.g.

Managem

ent. In fact, I get the feeling that my m

anager will be relieved w

hen it is over and CS doesn’t need to be a factor in the roster. (3M

12)” “O

ur NU

M saying to m

e that ‘I couldn’t give stuff if the whole thing (CS im

plementation) falls

over’. (5M3)”

Buus 2013

4 Positive attitude

"The most stressed, defensive, anxious or even hostile individuals or w

ards are probably those least likely to engage them

selves in the process of self-disclosure and reflection that would be

required to find clinical supervision useful”.

"Findings of White and W

instanley (2010b) that interventions promoting clinical

supervision probably have the best chances of a positive result when given to staff

with a prepared m

ind employed in w

ards actively engaged in clinical supervision"

46 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Cross 2012

12

Respect for clinical supervision and the supervisor

“Clinical supervision allows m

e to share professional ideas, reflect on situations of conflict or incidents w

here I feel boundaries are being overstepped. It encourages m

e to confront issues about myself and m

y perceptions of those I work w

ith that, for ease I otherw

ise would try to ignore or avoid. The supervisor provides m

e with

an objective perspective and asks questions that probe me to think beyond the

obvious. With tim

e the questions have become m

ore challenging and confronting and are som

etimes difficult to answ

er! To make the m

ost of each meeting I create

‘‘homew

ork’’ for myself as I leave in order to provide som

e connection to the next session (O

N1)”

“I mean it’s [the supervisor’s] tim

e too so it’s not just up to me to try and m

ake it, you know

I didn’t want to put him

out by saying can we m

ake another time

because he might have had other things to do so I think betw

een both of us it’s im

portant that we don’t, I don’t infringe on his other tim

e because he’s making

time for m

e (Interview).”

Turner 2005

103 Suspicious

"The group identified concerns regarding clinical supervision, which w

ere varied; whilst som

e felt it w

as going to be extremely useful and could not w

ait to start, others felt it was an added

pressure, suspicious that it was a paper exercise. There w

ere concerns that the process would

involve criticism and expose vulnerabilities, nevertheless all w

ere prepared to try it and see"

Abbott 2006

53 Value

“Provided an opportunity to "sit dow

n, wind dow

n, off-load and cool-off"

Bam

bling 2006

6 Value

“Therapists assessed supervision as an indispensable training activity that increased both self- and therapeutic aw

areness. Further, therapists have rated supervision highly as an educational procedure that develops treatm

ent skills and professional com

petency”

Bergdahl 2011

7 Value

“Regarded it as valuable that the supervision concerned their perceived problems

from their point of view

and then linked their experience to research or ethical theory: (‘The supervision has alw

ays started from our personal experience of a

problem, and then the group have been able to add their points of view

and solutions.’)”

Brink 2012

9 Value

‘‘. . .Through these sessions, we really did learn to be conscious of our ow

n attitude tow

ards some people, such as socially excluded people – in other w

ords, not treat them

in a humiliating w

ay. Now

, I look at it differently...” ‘‘... I also think it is im

portant to be able to elaborate on different solutions to a problem

together, such as ways of approaching a colleague w

ho does behave in a hum

iliating way...’’

47 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Brunero 2012

3 Value

"Clinical Supervision reduces my w

ork related stress’ ‘Improved team

morale’

‘Improved com

munication am

ongst the team’ ‘Increased team

collaboration’ ‘The nursing staff learnt about each other’ ‘Tim

e out from the m

undane workload’;

‘Feeling that they have a ‘‘sounding board’’ for any issues both positive & negative"

Buus 2011

96 Value

"Nurses acknow

ledged the value of the idea of clinical supervision, but that they did not regard it as feasible in everyday w

ork situations and considered it to be irrelevant and of limited value

(Cleary and Freeman, 2005)". "Costs of participating (w

orking over or interrupting days off) outw

eighed the benefits or because it was irrelevant for them

"

Cookson 2014

57 Value

“Cultural belief that clinical supervision has limited experiential value, because of existing

support systems in nursing”

Hall and Cox 2009

88 Value

“Clinical supervision was reported as being helpful as a w

ay of indicating areas for personal and professional developm

ent (n = 2) and providing a broader perspective (n = 4). Some participants

(n = 3) indicated that they would use clinical supervision m

ore when they w

ere just starting out in their career. O

ther participants (n = 4) reported that clinical supervision helped them m

ake the link w

ith CPD and reflective practice more explicit.

Interviewee G: I think it is part of your CPD…

. I think it’s a big part of it really because it made m

e reflect on things that I hadn’t thought about…

I don’t think it changed the way I deliver care but it

changed the way I thought about things…

Six participants reported it w

as helpful as a mechanism

for support other than their line m

anager as reported below:

Interviewee G: …

I think before I had that formal clinical supervision I w

ould have probably just used m

y line manager…

.in charge of me on the rotation…

.. I found it helpful going to someone

outside of that team because they have a different kind of slant on it and it w

as more about m

e and how

I developed…”

Koivu 2012

63 Value

"Receiving CS w

as associated with higher levels of perceived support, particularly

for hospital-based nurses of lower grades"

Livni 2012

17 Value

“supervision w

as generally a positive experience that was becom

ing more valued

the more tim

e people spent in supervision”

O

'Connell 2011

104 Value

“Multiple benefits identified:

Theme 1. Providing an independent forum

to debrief and address work issues

• “saved staff from “bottling things up,” allow

ed them to ask questions, and

enabled them to challenge existing practices and seek solutions. They felt

comforted by being able to voice concerns, “get things off their chest,” and “feel

48 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

listened to.” Them

e 2. Improved com

munication

• Enabled them to acknow

ledge their individual differences, better support each other, and increased their respect for one another. It also assisted som

e staff m

embers to clarify the different roles of staff on their w

ard, and the expectations associated w

ith these roles, and to identify who they could approach for help in the

future. Them

e 3. Reducing stress and improving w

ell-being • Assisted them

to reduce levels of stress and “let go of issues.” • O

ne senior staff mem

ber acknowledged that nurses’ exposure to stress in the

workplace differed depending on their position, and som

e of the stressful issues in the w

orkplace were unresolvable by attending TCS

Theme 4. Enhanced problem

-solving skills • Developed new

and systematic approaches to m

anage complex issues involving

patients, families, colleagues, and the m

ultidisciplinary team.

• Previously been a culture of “sweeping issues under the carpet” and an

acceptance that they were not in a position to m

ake changes • Graduate nurses w

ho had participated in the TCS reinforced how useful they

found the program in term

s of assisting them to voice concerns and elicit

appropriate support. This encouraged them to continue w

orking in particular wards

instead of transferring to other wards at the end of the graduate year”.

Turner 2011

19 Value

“Respondents identified clinical supervision as ‘enabling’ and ‘two-w

ay process’ involving know

ledge and skills development w

here the objective self evaluation of skills w

as experienced. "Respondents made num

erous comm

ents relating to the positive effects of focusing on support in supervision (Table 3). They ranged from

‘feeling valued’, ‘I enjoyed the process’ and ‘to be used to its best advantage a relationship of trust, respect and understanding needs to be developed’. "Tim

e for supervision seem

s to be important. O

ne respondent stated: ‘It’s good to have a form

at that is time out from

day-today shift work, in that areas of professional

practice and interaction can be looked at either in depth or superficially without

being interrupted and as the supervisor has more ‘‘experience’’ can often either

regain your focus or offer an alternative perspective.’ Value is inherent in this statem

ent – the value for time out and safe tim

e, free from

interruptions. Time out is im

portant, as in one session there were constant

interruptions that caused much irritation and frustration"

W

allbank 2012

72, 97 Value

"Can I also take this opportunity to express how beneficial this training has been …

a real lifeline for m

e. I honestly think I may have left m

y post (if not the NHS) if this

course had not helped me rediscover m

y passion and comm

itment to health

visiting and re-examine the skills I though I'd lost. It w

as perfect timing and I cannot

measure the personal value it has been to m

e"

49 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

W

allbank 2013

71 Value

"Professionals report: 'Feeling stronger and having greater thinking capacity'; post sessions and cite that the program

me supports them

to 'interact more positively in

the workplace, w

hich benefits both the rest of the team and the fam

ilies or patients they are w

orking with”

Bow

ers 2007

8 Value (m

aking tim

e)

"Mem

bers of the forum believed that m

aking time for supervision w

as important

demonstrate the positive value they placed on the experience.”

Cutcliffe 2006

87

Identifying existing attitudes

“the importance of attitudes in the context of CS that any attem

pt to introduce it into practice is prefaced by the need to exam

ine prevailing attitudes (Hancox et al. 2004). The same authors

continue,_ unless nurses were receptive to the idea of receiving supervision and view

ed the (introduction) strategy positively, it w

ould be unlikely that the widespread introduction of

supervision would take place” (Hancox et al. 2004, p. 199)

“Utility in undertaking such endeavours before one attem

pts to introduce CS into practice and as a m

eans to further our understanding of any associated resistance to CS”

Boundaries Abbott 2006

53

Clarifying roles and responsibilities

“The staff involved (supervisors, supervisees and managers) w

ere defined in guidelines that form

ed part of the clinical supervision policy, and contracts were

signed by managers to ensure that staff w

ould have protected time for clinical

supervision”

Alleyne 2007

54

Clarifying roles and responsibilities

“Professional nature of the supervisory relationship, where boundaries are clearly

defined, was recognized by all the participants as an im

portant element in creating

a climate w

here concerns could be freely explored and creative approaches to personal and professional developm

ent identified and acted upon”

Hall and Cox 2009

88

Line m

anagement?

“Some participants associated clinical supervision w

ith line managem

ent. This is a comm

on m

isunderstanding that also occurs in other healthcare professionals (Sweeney et al. 2001a,b,c;

Sellars 2004) and in this study seemed to be reinforced by the term

inology used implying

competency and accountability issues (Sw

ain 1995; Gilbert 2001; Sweeney et al. 2001a,b,c).

Sweeney et al. (2001a,b,c) in their w

ork with O

ccupational Therapists suggest that supervisory relationships associated w

ith line managem

ent may have lim

itations. Supervisees may becom

e defensive about their practice and be unable to ask for help as they w

ant to give the impression

of being a ‘competent and adequate’ practitioner (Sw

eeney et al. 2001b). They also suggest that this is a difficult relationship for the supervisor w

ho, as the line manager, can find it difficult to

challenge and confront, influence and facilitate the supervisees’ professional development

(Sweeney et al. 2001a) Scanlon &

Weir (1997) in their w

ork with nurses. They indicate that

tensions will arise in clinical supervision if the purpose, structure and boundaries are not clearly

defined and understood by supervisees, supervisors and managers (Scanlon &

Weir 1997)”.

Abbott 2006

53 Link to m

anagement

"groups needed a clearer link to managem

ent, to ensure that changes resulted from the

sessions"

50 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Jarrett 2014

61 M

aintaining boundaries

"Som

e home visitors reported that clinical supervision had better enabled them

to establish and m

aintain professional boundaries with the fam

ilies"

Rice 2007

85 Purpose of CS unclear

“Howatson-Jones (2003) suggests that clinical supervision is often underused because of

misinterpretation, problem

s with organizational endorsem

ent and supervisory relationships, and lack of funding or tim

e”

Turner 2005

105

Negotiating

organisational boundaries

"Perceived lack of managerial support and the difficulties encounter in negotiating

organisational and professional boundaries were identified as tw

o of the biggest factors contributing to stress"

Clinical supervision has shown us how

to do this, and the importance of

acknowledging these issues. It has helped us identify the lim

its of our responsibilities and w

ith the help of our supervisor we have clarified our role in

different work situations"

Ayres 2014

55 Purpose of CS unclear

"Lack of clarity about its purpose and practice (Gaitskell and Morley 2008)"

Boland 2010

92 Purpose of CS unclear

“Another issue regarding supervision that was considered by participants as problem

atic was the

supervisee’s understanding of what supervision entails and the need for both supervisors and

supervisees to acknowledge responsibilities for the learning w

ithin supervision”

“Supervision was acknow

ledged to be a formal process to develop the supervisee’s

professional ability. How

ever, it was felt that a clear definition of supervision w

as needed for the industry”

Buus 2013

4 Purpose of CS unclear

"Creating a safe learning environment for all participants is com

plex as they may w

ell be asking them

selves basic questions regarding the groups: “Will I be safe?” “W

ill I be seen as com

petent?”

Buus 2011

96 Purpose of CS unclear

"On the negative side, the nurses found that supervision w

as badly timed, did not have the right

focus, and was not needed."

"Nurses stated that it w

as important to be explicitly aw

are of the purpose of clinical supervision and carefully schedule tim

e for it. On the positive side, the nurses

found that clinical supervision provided them w

ith time for reflection, confirm

ation of thoughts and feelings, new

perspectives, and an increased sense of collaboration that enabled them

to relate better to patients"

Chilvers 2009

10 Purpose of CS unclear

"Individuals’ perception that clinical supervision was an ‘add on’ and not of any sound benefit to

their role"

Cookson 2014

57 Purpose of CS unclear

"Confusion about the purpose of clinical supervision, with a w

ide range of theories and models

employed across health and social care professions. In addition, conceptual fram

eworks do not

always transfer betw

een disciplines due to cultural and organisational differences, and the unique roles and responsibilities of different professions (Cleary and Freem

an 2005)"

51 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Cross 2010

11 Purpose of CS unclear

"Scepticism and m

istrust about its purpose. Several authors suggest that there is a degree of resistance and m

istrust of CS among nurses. Given the range of definitions of CS in the literature,

it is likely that nurses are unclear about its purpose and perceive supervision in a negative light and related to perform

ance managem

ent"

Hall and Cox 2009

88

Purpose of CS unclear

“For many of the participants (n = 7) the purpose of clinical supervision w

as unclear. This was

reported in a variety of contexts in the transcripts, for example: Interview

ee G: …I think w

hen it w

as first set up it was kind of like w

e all had to do it but I wasn’t keen on doing it because I didn’t

really have anything to say and I thought at the time I w

as newly qualified and I didn’t know

really w

hat to say in it so I was nervous about going to it…

”

Long 2014

91 Purpose of CS unclear

“The finding that staff meetings (not designated for CS) are view

ed as opportunities for CS indicates both a lack of understanding of the process and the lack of opportunity for form

al supervision”

Lynch 2008

64-67 Purpose of CS unclear

“‘Myths’ and m

isconceptions that frequently surface when this initiative is introduced”

“Education and training is required in order that both supervisors and supervisees have a clear understanding of clinical supervision, free from

the many”

O

'Connell 2011

104 Purpose of CS unclear

“Pre-reading m

aterial about TCS prior to comm

encement to provide a context and

give them a better insight into w

hat it involved”

Taylor 2009

69 Purpose of CS unclear

“Clinical supervision, some m

embers of the team

were unclear w

hether its purpose was clinical

supervision or managerial supervision. These factors presented a challenge to developing a

constructive method of group clinical supervision”

Effective socialization to group clinical supervision was essential, as w

as identifying the team

’s understanding of supervision and dispelling misconceptions about it.

Getting this right was param

ount to the success of the novel method of group

clinical supervision that the trainers wished to introduce.

Choice Evans 2015

14

Choose supervision package

“Staff choose their preferred method of supervision from

group-facilitated supervision, reflective logs, clinical specialist/ peer supervision, peer review

and action learning sets. They select m

ixed methods from

the menu, subject to agreed

parameters, to enable them

to reflect and develop through supervision. Supervision is both adaptable and tailored to individual staff and service needs. In practice, this is challenging but m

ust not be a barrier to the provision of clinical supervision. Com

munity has found that clinical staff are m

ore likely to engage in the clinical supervision process if they have a m

enu of options because they can access supervision at a tim

e convenient to them and in a form

at that suits their individual learning needs and style”.

52 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Daw

son 2012

84 Choosing a supervisor

"Low rate (26.7%

) of respondents choosing their supervisor in the current study may be a factor

in the quality of the supervisory relationship and the ability of the relationship to explore personal issues. W

instanley suggested that the ability to select a supervisor enhances the quality of the supervisory relationship, w

hich may lead to greater capacity for trust and greater

potential for disclosure of personal issues"

Girling 2009

15 Choosing a supervisor

“Supervisees w

ere discouraged from seeking supervision from

their line managers

to avoid blurring the boundaries between m

anagerial and practice supervision"

Edw

ards 2005 &

2006

94, 106

Choosing own

supervisor

"Choice of supervisor had an effect on the effectiveness of clinical supervision. Those supervisees w

ho had chosen their supervisor had higher overall scores on the M

CSS and on the sub-scales of trust/rapport and supervisor advice/support". "W

ebb & W

heeler (1998) found that supervisees were m

ore likely to disclose personal inform

ation in supervision when they had chosen their supervisor and

when they w

ere supervised by somebody independent of the setting in w

hich they w

ere employed"

Abbott 2006

53 Choosing ow

n supervisor

“Some people choose to be in groups w

ith their colleagues, which m

ay limit how

much can be

learnt, while if a staff m

ember and their m

anager are in the same group, this m

ay be inhibiting" “M

ost supervisees were given the opportunity to identify w

hich group they would

like to attend”

Ayres 2014

55 Choosing ow

n supervisor

“Current research evidence that indicates group supervision is more efficacious than one-to-one,

as is the supervisee choosing, rather than being allocated, their supervisor and group"

Cerinus 2005

56 Choosing ow

n supervisor

"The importance of choice in clinical supervision partnerships, although not referred to directly,

was considered im

portant by several participants as it facilitated their establishment and the

subsequent development of sound relationships built on trust and confidentiality. ‘There are

people who I can sit and “blether” to in the tearoom

and things, and you could have partnered m

e up with them

. I would never trust them

, although I get on fine with them

.’ (Katy)"

"Starting off in their respective clinical supervision relationships had been made

easier because they already knew their partner. ‘I found it quite easy. The fact that

I knew her [m

y partner], I trust her and I felt as if I could say anything to her. Sitting listening to others in the group, they feel m

ore comfortable discussing professional

matters w

ith someone they don’t know

, so I think it’s down to the personality and

what you feel com

fortable with yourself.’ (Dorothy)" the im

portance of choice, that is, being able to choose one’s ow

n clinical supervisor. ‘I think it [choice] is im

portant. I think it’s necessary to be able to choose your supervisor.’ (Nora)”

Chilvers 2009

10 Choosing ow

n supervisor

“Areas of concern. The first was ‘can staff sw

ap groups?’: this was felt to be inappropriate. Staff

mem

bers were selected based on skill m

ix and are all professionals. Clinical supervision is meant

to enhance clinical practice and not be a ‘moaning’ session. If staff have had previous conflict

supervision may be an opportunity to resolve it. N

ormally conflict occurs through lack or

misinterpretation of com

munication. How

ever, if there were real concerns the m

ember of staff

was encouraged to speak to their line m

anager”

53 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Cookson 2014

57 Choosing ow

n supervisor

“The guideline, in line with m

ost research, recomm

ends that wherever possible professionals

should have the opportunity to choose their clinical supervisor. In this sample, m

ost of the AHPs chose their supervisor. Conversely, a larger proportion of nurses had theirs allocated. This could reflect a num

ber of things: (1) The resources available in m

ental health nursing influencing supervisor choice. (2) The historic culture of appointing line m

anagers as clinical supervisors. (3) O

rganisational necessity. (4) The com

plicated implications of allow

ing a large professional group to choose their clinical supervisor”

“Importance of supervisors providing an unbiased perspective and ‘distance’ from

the daily routines of supervisees’ clinical practice. it has been suggested that if professionals choose their clinical supervisors, this can im

prove the supervision relationship and effectiveness (W

instanley and White 2003, Edw

ards et al 2005, Driscoll 2007, W

hite and Winstanley 2011)”

Cutcliffe 2006

107 Choosing ow

n supervisor

“Where the respondents could choose their ow

n supervisor, they in majority (78%

) elected not to have a line m

anager act as a supervisor”

Hall and Cox 2009

88

Choosing own

supervisor

“Six participants reported that having the choice of a clinical supervisor was an

important aspect of the clinical supervision process (N

icklin 1995) and enhanced the supervisory relationship (Haw

kins & Shohet 2000; Sw

eeney, Webley &

Treacher 2001b,c; Sw

eeney et al. 2001a)”

Davis 2012

59 Choosing supervisor

"Choose their own group supervisor (U

KCC 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). O

ther relevant factors are the need for supervisors to receive supervision them

selves (Fowler 1996) and for

implem

entation to comm

ence as a bottom-up process, m

eeting the needs of junior staff first”

Girling 2009

15 Finding the right supervisor

“Staff were enthusiastic but expressed concerns about finding the right supervisor”

“To ensure staff were kept up to date w

ith progress the facilitator circulated quarterly new

sletters. The identification of 'champions' is seen as key to success to

projects…their com

mitm

ent and enthusiasm has been critical to the project's

success"

Turner 2005

105

Identifying im

portant qualities in a supervisor

"Som

eone who could speak and understand our nursing "language"; som

eone with

a clinical background; someone w

ith experience of working w

ithin a large organisation like the health service”

Comm

ercial Boland 2010

92

Comm

ercial im

plications from

private practice

“There was considerable debate about the barriers to supervision in the industry. Participants

identified main barriers to supervision practice in current Q

ueensland work rehabilitation

practice as the need to meet com

mercial targets, lack of exposure to w

ork rehabilitation in university curricula, high staff turnover, the relative inexperience of case m

anagers in taking on influential positions w

hich potentially require the delivery of supervision, and purchasers dictating product outcom

es to industry. Comm

ercial targets were considered to be a reality in

“It was recom

mended that the industry develop and im

plement supervision

standards in order to nurture and develop skills of the professionals working in this

area. An industry definition and standards for supervision may enhance the

understanding of and effectiveness of this practice, while providing an avenue for

overcoming the barriers identified in this study”

54 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

many parts of the sector. The ‘billable hours’ requirem

ents were seen to be a disincentive to

employers providing supervision, and to rehabilitation consultants seeking supervision.

Monetary bonuses w

ere also described as a barrier to supervision in some cases, as new

professionals m

ay focus upon increasing billable hours during their probation rather than directing their attention to fully extending them

selves in the profession. A perceived lack of exposure of new

graduates to work rehabilitation practice w

as seen by focus group participants to result in inexperienced professionals w

orking in a field in which sole w

ork is comm

on practice. This, com

bined with infrequent or even non-existent supervision practices and the drive for

comm

ercial targets, may contribute to low

retention rates of practitioners in this field. Participants reported that w

ith a low staff retention rate less experienced professionals m

ay be entering into m

anagerial positions ill equipped to provide effective supervision”.

Confidentiality and trust

Cutcliffe 2006

107 Confidentiality

“Confidentiality is assured and agreed [highest (mode. 1)]. Alm

ost all eight professional groups ranked this item

as the most im

portant characteristic for group supervision …“vast m

ajority of participants in this study (alw

ays more than 90%

) and across all the various disciplines and specialties, held the attitude that confidentiality is assured and agreed. It the issue of m

anagers also acting as supervisors and the resultant conflicts and confusion that this can (and does) create, w

ill be neither new nor surprising. This confusion is w

ell documented in the literature

(see White 1996, Butterw

orth et al. 1997, Cutcliffe & Proctor 1998a,b, Deery 1999, Yegdich

1999, Cutcliffe 2003, Hyrka¨ s et al. 2005, 2006). Yet, no such confusion or conflation with

administrative/m

anagerial supervision (AM/S) w

as ever intended in the original conceptualizations and justifications for CS”. “In Finland, having m

anagers, first-line managers or Head N

urses acting as clinical supervisors w

ith their subordinates would be in direct contradiction of the recom

mendations of the M

inistry of Social Affairs and Health"

Hall and Cox 2009

88 Confidentiality

“Participants reported anxieties in the process particularly because the physiotherapy departm

ent was sm

all and trust in the supervisory relationship (n = 4) was im

portant. Interview

ee D: …because it is so sm

all and because we all end up crossing paths at som

e point during the day I think it could be difficult for som

eone to maybe fully open up about a problem

that they had…

”

Turner 2005

105 Confidentiality

"M

ost important", as this w

as the foundation stone for providing a safe environm

ent in which to explore com

plex issues”.

White

and W

instanley (2009 &

2010) 23,

77-81

Confidentiality

“One of the crucially im

portant ground rules of group CS, particularly in the early establishment

of CS arrangements, is universal respect for the confidential nature of disclosures m

ade by supervisees. W

hen this was threatened, not only w

as the efficacy of the sessions endangered, but also the culture base of the host organization w

as exposed. Following this session, I w

as called into the Team

Leader’s office and asked if I had anything to tell (gender)? When I queried

what (gender) m

eant (gender) explained what (gender) had overheard m

ention of the Team

Leader and thought I may w

ant to tell (gender) what w

as discussed (in the CS session). I politely

55 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

declined, but did not discuss further. I had thought that the location we w

ere using would have

been soundproof, unless someone cam

e into the deserted offices between the deck and the

corridor, which indicated to m

e that the Team Leader had entered these offices, in order to hear

what w

as being discussed. (9M8)”

“I was approached by m

y NU

M re how

(gender) could find out what happens in supervision.

(Gender) stated this had come from

further up the chain of comm

and. M

y response was that this obviously indicated a distinct lack of understanding of CS at the higher

managem

ent level. I also informed (gender) that w

hat was discussed in supervision stayed in

supervision and, unless there was a breach in the Code of Conduct…

”

Girling 2009

15 Confidentiality

“Staff were enthusiastic but expressed concerns about confidentiality”

Cerinus 2005

56 Confidentiality and trust

“Trust was identified as an essential com

ponent of empathy, the essence of a safe

environment (confidence) for effective supervision to ensue. If there w

as no trust, there w

as no relationship. If there was no relationship, there w

as no effective supervision. In this study, w

hile knowing one’s partner appeared to aid initial

comfort w

ithin the relationship, it was the developm

ent of trust and confidence that w

as the key to that relationship becoming m

ore purposeful, affirming Jones’

finding. Effective relationship development w

as evidently important to effective

clinical supervision even at this early stage”.

Cox 2009

58 Confidentiality and trust

“I felt up to recently I didn’t have faith in my therapy leads ability and this created a barrier to

comfortably taking on board criticism

s given to me about m

y practice…”

Cross 2010

11 Confidentiality and trust

"Ground rules that might be established w

ere discussed, such as confidentiality (w

ithin the limits of safe practice), tim

ing of sessions, and the role of the supervisor. The PCLN

did not have a reporting line with the AN

UM

S. This enabled the CS to be separated from

line managem

ent and provided a safe ’space’ for participants to engage".

Davis 2012

59 Confidentiality and trust

“Multi-disciplinary attitudes tow

ards clinical supervision. A total of 17 statements about clinical

supervision were used in the previous study. Findings show

ed that one item – confidentiality –

scored the highest across all the disciplines in terms of im

portance as a characteristic of the clinical supervisor. The least im

portant characteristic was seen as the need for the clinical

supervisor to be a manager. This dem

onstrates that the clinical supervision relationship is separate to the m

anagerial relationship and that maintenance of confidentiality is of param

ount im

portance”.

56 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Edw

ards 2005 &

2006

94, 106

Confidentiality and trust

“W

ilkin (1992: 192) suggested that ‘the important factors for selecting a

supervision partner seem to be m

utual trust, respect for each other and feeling com

fortable in each other’s presence’”

Knowledge and

Skills Abbott 2006

53 An opportunity to learn

"Could learn from

others, solve problems, look at issues from

a wider point of view

, and learn from

the skills and insights of the facilitator"

Bailey 2014

5 An opportunity to learn

“Group discussions often stimulate m

embers’ thinking about the people w

ith w

hom they them

selves are working, w

hich provides mutual benefit for presenter

and group” Peer supervision groups “seen as one remedy to the risks associated

with isolation, and a support to good practice” ( “I am

grateful that you have set up this regular peer supervision, as it is m

uch needed in a rural area . . . where it is too

easy to work in a vacuum

. Being part of a group gives a sense of connectedness and reduces feelings of isolation w

hich is beneficial for clients and practitioners.”)

Bow

ers 2007

8 An opportunity to learn

"Strong perception from

the mem

bers that they have drawn on each other’s

knowledge and developed as a result of attending "

Brink 2012

9 An opportunity to learn

"Group supervision also creates conditions for a group of colleagues to enhance their professional learning and im

prove their effort" ; “opportunity for group supervision w

ill be a means of developing professional skills" ; ‘‘. . . w

e address attitudes and behaviours in relation to patients, colleagues and each other. W

e don’t use the concept of debriefing, but, during the group sessions, w

e have been able to talk about ‘sm

all’, everyday problems...’’; ‘‘. . . w

hen you’ve got a lot of sm

all suppressed problems and conflicts, it is great to be able to deal w

ith these problem

s in this group. . .’’

Brunero 2012

3 An opportunity to learn

‘To learn m

ore about care plans, medication, handling and adm

inistration of’ ‘Scheduled Drugs, Progress notes, CVC Care, Pressure area care’ " better problem

solving"

Evans 2015

14 An opportunity to learn

“Learning should bring about change and im

prove care and Learning needs identified in supervision should feed into appraisals”

57 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Gonge 2010

24 Credibility

"A recent review of em

pirical studies of clinical supervision in psychiatric nursing concluded that there w

as limited em

pirical evidence substantiating this assumption"

“Clinical supervision is generally considered to be a good thing (Mullarkey, Keeley,

& Playle, 2001; Sloan, 2006)"

Bailey 2014

5 Evaluating CS

"Groups w

ithout specified leadership to establish regular internal evaluation, as w

ell as evaluation conducted by an outside supervisor"

Cookson 2014

57 Evaluating CS

(See Box 1 and 2, p16)

Bailey 2014

5

Exposure to practice diversity

“Professional practice can become overly patterned and habitual through lack of stim

ulation and exposure to alternative approaches and m

ethods"

“An opportunity to move in different directions, like string theory, noticing patterns

in own style as w

ell as others. Helps reflect on alternative approaches”; “I think the biggest influence m

y participation in the PCG has brought is the great diversity of approaches and outlooks of therapy as w

ell as our own personal expectation of

ourselves in our professional work. I feel blessed to not feel pressured to produce

outcomes”; “It’s nice to m

eet peers who practice in different sectors and

understand better some other services”; “It has been m

ore focused on relevant issues of practice w

ith good input from others. It is the first that I have attended

with such a variety of therapists”; “Having participants from

different organisations has been helpful and com

plements exchange”

Long 2014

91

Integrity m

onitoring and evaluation

“Reference is often made to ‘good enough’ supervision (Flem

ing & Steen 2004) but

it is not always clear w

hether this standard is met w

ithin the supervisory process. W

hile attempts to evaluate CS system

s are notoriously difficult, attempts to

monitor integrity (the extent to w

hich it is delivered as intended) are important.

This is accomplished in the current setting by structuring CS sessions to cover

specific topic areas and the use of audited supervision logs to ensure this (Rafferty et al. 2000). N

ursing staff are required to bring to individual performance review

m

eetings on a six monthly basis a signed (by supervisor) record of sessions

attended and a record of a broad outline of topics discussed (such as blocks to w

orking therapeutically”

Bergdahl 2011

7 Lack of know

ledge "External conditions: lack of know

ledge, or we m

ay have judged the situation differently from

the other unit"

58 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Long 2014

91

Need for

education and training

“Need for education and training for both supervisors and supervisees w

as a significant theme”

Ayres 2014

55 Poor evidence-base

"Little research into the effectiveness of supervision within occupational therapy"

Bam

bling 2006

6

Poor evidence-base (issue of credibility)

“Little empirical evidence exists regarding the effect of supervision on achieving m

easurable clinical outcom

es for clients”. "Multiple problem

s with the existing evidence: “criticism

of the supervision literature includes problem

s of inadequate power, poor m

ethodology, Type I and II errors, and an absence of outcom

e research”

Best 2014

82 Q

uality of supervision

"On the contrary, som

e of the concerns included ‘‘incongruence of modalities betw

een supervisor and supervisee’’ and ‘‘too rigid w

ith not enough scope to discuss non-clinical issues’’ and ‘‘concerned that the supervisor has identified no background or skills in particular aspects of clinical supervision.’’

“In terms of quality of supervision, there w

ere many positive com

ments from

respondents, including ‘‘It’s very useful and supportive’’ and ‘‘It gives m

e the opportunity to discuss, affirm

and build confidence in my practice.”

Bergdahl 2011

7

Supervisors expertise and know

ledge

“The supervisor herself was an experienced nurse: ‘supervisor’s know

ledge and background w

ere considered important by the participants, ("the supervisor is w

ell read in nursing theory and has a solid background in the profession itself; that is the strength of this group supervision") .

Cerinus 2005

56

Supervisors expertise and know

ledge

“About one-third of participants thought that having a different clinical background from their

clinical supervision partner was not a problem

. ‘I wouldn’t personally like som

ebody from m

y ow

n area as my supervisor. I don’t think it’s necessary at all. W

ell, one thing that concerns me, in

your own area, to be quite frank about things, confidentiality w

orries me terribly. And I think if

it’s someone rem

oved from your ow

n area, then it’s less likely to be a breach of that confidentiality. Because, as nurses, w

e have comm

on experiences, regardless of where w

e work,

without a doubt.’ (M

aggs) "A clinical supervision relationship also had to offer an element of

challenge for maxim

um effectiveness, a challenge that can only be provided by som

ebody more

‘senior’, that is with greater capabilities than oneself. This m

ay be elusive in peer supervision. ‘Given that you’re in a position of selecting your supervisor, truthfulness is needed. If that dissipates so does the quality of supervision. I am

seeking to be supervised by someone w

ho I perceive as being m

ore experienced than myself. So you seek constant criticism

and challenge from

clinical supervision and respond to it.’ (Babs)"

Cox 2009

58

Supervisors expertise and know

ledge

“Other barriers related to the interaction betw

een level of expertise and knowledge of

supervisor and supervisee to enhance professional development ("supervisor did not know

local procedures and their im

pact on the trial and that it was difficult for supervisor and supervisee

located at long distance from each other. Individual perceptions of their supervisor’s capacity or

incapacity could help to create or shape barriers against positive comm

unication. Although this could be (and probably rightly so) interpreted as a pre-judgem

ent of the supervisor’s capacities

59 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

by the supervisee, it nevertheless highlights the inter-subjective sphere of supervision, which

was to be understood as a personal relationship that w

ould not always be straightforw

ard and clear, as it im

plies the subjective perceptions and lives of both persons”.

Girling 2009

15 Training

"It w

as deemed im

portant to train supervisees as well as supervisors because the

supervisory process involves making sure that they fully understand the roles in the

process. Three one-day workshops w

ere held"

Brunero 2012

3 W

ide range of specialities

“Implem

enting clinical supervision (CS) in hospital settings still remains a significant hurdle for

the nursing..”; “broad range of nursing specialties within large hospital-based”

Logistics Abbott 2006

53 Adm

inistration "Confusion about tim

es and places" “Im

proved planning and organisation ("were given dates, tim

es and venues for 12 m

onths ahead”)

Chilvers 2009

10 Adm

inistration

“Facilitating attendance at CS sessions: letter was devised w

hich was to be sent to

supervisees introducing the supervisor, listing dates, times and venue for the

meetings to take place”

Turner 2005

105 Agreeing ground rules

"Agreeing ground rules using the outline developed in the workshop. The first

session was used to explore our expectations of the supervisor and her

expectations of us. It was highlighted by the supervisor their responsibilities should

a situation occur when they m

ay have to break the rule of confidentiality if a clinical risk w

as identified. They also outline her responsibilities to us. The ground rules included: confidentiality seen as essential to build a safe and trusting environm

ent; tim

e keeping and attendance; frequency and duration of each session; date for review

process”

Davis 2012

59 Attendance

“Reasons for non-attendance cited annual leave, sickness, work pressures, childcare problem

s and poor im

plementation. Tim

e pressures were the m

ost frequently mentioned”.

Evans 2015

14 Attendance

“Records of attendance and learning themes in facilitated groups”

“Development of a facilitator log book and online reporting tem

plate”

60 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Turner 2005

105 Attendance

“Identified as an important issue by the group “

Boland 2010

92

Availability of supervisor/sessions

“Thirty percent of respondents indicated that the availability of their supervisor/supervisee has also often caused difficulty in the receipt/delivery of supervision, w

hile the lack of supervision sessions w

as identified as often a problem for 26%

of participants”.

Buus 2011

96 Continuity of CS sessions

"Clinical supervision was not offered continuously by the hospital. This m

eant that the eventual effect of supervision w

ould never affect enough nursing staff mem

bers to influence everyday clinical w

ork"

Cross 2010

11 Dedicated tim

e

“We just had tim

e to talk about whatever issues w

e wanted to, w

e just spent that hour discussing personal issues, clinical issues, how

we feel about w

ork.” “I certainly appreciated the opportunity to be given tim

e to concentrate on those sorts of issues.” “I think it’s helped m

e in providing support to other staff mem

bers. When they

come to you w

hen they’re upset about something or affected by anything [the

supervisor’s] sessions have helped me to learn skills in dealing w

ith important stuff

really.” “I know

over the course of this time w

e had debriefing for staff relating to some of

the critical incidents that happened on the ward, but there’s never really been

anything for us, and often we’re the ones that cop it, because w

e’re up on the north end of the roster. They kind of forget about us, w

e need support as well”

Cox 2009

58 Distance from

supervisor

“Only barrier to supervision that w

as identified by respondents from all professional groups w

as their distance from

supervisors. This may relate to the previous m

ost comm

on experience of on-site, face to face supervision”

Turner 2011

19, 108 Docum

entation

“Evaluate the usefulness of documentation, w

hether or not the use of documentation w

ould facilitate the process of supervision (Table 6). Q

18 saw a m

ove from ‘undecided’ to ‘agree’ and

‘strongly agree’ that the use of documentation ‘enables practitioners to becom

e empow

ered in the supervision process”; “docum

entation seemed to be restrictive and difficult to w

ork with on

the next session cause it wasn’t w

here I was at ‘‘now

’’.

“Supervisees to decide the standard for documentation, not the supervisor, or to

adjust the nature of the documentation.”

“One respondent kept their notes at hom

e and found the process of using docum

entation made it ‘easier to reference specific subjects and over tim

e could be used to recognise constant them

es which could be developed’. O

ther respondents noted that structure aided clarity and joint understanding encouraging a ‘degree of fluidity’ in the supervision process. O

n balance it seems that

documentation can enhance the clinical supervision experience provided that it is

used in a reflective manner”.

“One reflection on the design of the form

for each session was that w

e soon dropped the signature as it seem

ed pointless and controlling, because ‘people

61 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

clearly were already m

otivated towards the supervisory process’”.

“Documentation that is relevant and m

ay or may not be kept by the supervisee is

recomm

ended to facilitate the process of clinical supervision. In setting the ground rules, developing sessions and follow

ing them through over tim

e documentation

has a valuable place to play in clinical supervision”.

Evans 2015

14 Engagem

ent “Staff engagem

ent: non-attendance at groups, limited use of reflective logs to record learning”

“Development of supervisee log books and reporting/follow

up of non-attendance w

ith line managers”

Bow

ers 2007

8 Establishm

ent of ground rules

“To explore issues in a safe, supportive and constructive environment, w

ithout an outside clinical supervisor, m

embers defined som

e specifically focused ground rules • Participation: The forum

belongs to every staff nurse and it is up to each person to decide its direction. • Confidentiality: The content of discussions in the forum

remains confidential

between the m

embers of the group. If unsafe or unprofessional practice is

disclosed, mem

bers will support each other in form

alising, at the time, how

the individual concerned (or other m

ember of staff) w

ill bring these issues to the attention of the person’s line m

anager. • Content of discussions: Every m

ember is invited to bring up any clinical issue

within their w

orking day that they would like to discuss w

ith peers. There will be no

negative criticisms of personalities w

ithin the sessions. All mem

bers are invited to give feedback on a subject. • Chair: The chair of each forum

is to rotate between m

embers. The chair’s

responsibility is to ensure that each mem

ber of the forum has a chance to openly

express his or her views. It is also the chair’s role to m

ove discussions on from a

subject depending on the time restraints and the subject’s com

plexity and/or sensitivity. • Sensitive subjects (note: added as a result of the forum

’s audit): The group will

access an outside clinical supervisor if mem

bers want to explore a sensitive subject.

It is down to m

embers to decide w

hen a subject is sensitive and to leave the topic until the next session w

hen an outside supervisor can facilitate the discussion. • Action plans: The group is to decide w

hat actions are to be taken as a result of their discussions and how

this is to be fed back in future sessions and to other m

embers of the district nursing team

s. • M

inutes of forum: Brief and non-detailed m

inutes of the forum w

ill go to each m

ember”

Abbott 2006

53

Facilitators (internal vs external)

"Majority thought that supervision (w

ith internal facilitator) would feel less confidential and

more inhibiting"

"Some staff felt that facilitators w

ho were both clinicians and m

anagers might help

to lead to changes arising out of issues brought to clinical supervision"

62 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Evans 2015

14 Flexible

“Clinical supervision m

ust fit around work settings and individual learning needs

and styles”

Best 2014

82 Frequency of supervision

"Some of the concerns in relation to frequency included ‘‘not enough,’’ ‘‘ad hoc,’’ ‘‘often put off

at short notice,’’ and ‘‘assigned once a week and it doesn’t happen". ("a range of areas in w

hich clinical supervision could be im

proved was reported. Specifically, staff indicated that they

needed a greater frequency and consistency (27.3%) and greater variety of form

ats to include group and peer supervision (15.2%

), or a higher degree of support (6.1%) or structure (9.1%

) in their sessions. A sm

all proportion of participants felt that the current system needed a com

plete review

(15.2%)"

"In terms of satisfaction w

ith the frequency and quality of clinical supervision, most

staff mem

bers reported their level of satisfaction was ‘‘quite a lot.’’ Those w

ho w

ere happy with the current arrangem

ent comm

ented, ‘‘monthly is the right

interval’’ and ‘‘it’s great to have supervision at least every 4– 6 weeks"

Abbott 2006

53 Group com

position "Staff had not initially w

elcomed m

ultidisciplinary groups" "com

e to value the chance to learn about each other’s roles, and about similarities

in their experiences" "single discipline groups can become rather introverted: it is

good to have assumptions and routines questioned"

Bergdahl 2011

7 Group supervision

"N

umber of sessions and the structure of the group supervision w

ere regarded as highly suitable by the nurses. The w

hole group wanted the group supervision to

continue and wanted their colleagues to have the sam

e opportunity”.

Ayres 2014

55

Importance of

good docum

entation

"Comprehensive guideline for the supervision of occupational therapy staff set out

the service expectations of supervision: a definition, the principles for effective supervision, contract setting, recording, duration and frequency, issues of confidentiality, the content of supervision (including clinical, adm

inistrative tasks /m

anagement, professional developm

ent and training, and support), and the benefits of supervision to both the organization and the individual."

Cookson 2014

57

Importance of

good docum

entation

“Use of a supervision agreem

ent (See Box 1 and 2, p16)”

Abbott 2006

53 Lack of tim

e "Som

e nurses had heavy workloads"

“Contracts were signed by m

anagers to ensure that staff would have protected

time for clinical supervision"

Bergdahl 2011

7 Lack of tim

e O

ther external barriers mentioned w

ere "lack of time, com

munication and resources"

63 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Boland 2010

92 Lack of tim

e “Forty four percent of all respondents indicated that a high caseload has often caused difficulty in the delivery/ receipt of supervision in the past tw

o years”.

“It was seen as im

portant for organisations to make the tim

e for supervision, and to ensure that they have the capacity to provide effective supervision. This m

eans ensuring that the supervisors in the organisation have the professional experience and training to deliver effective supervision”

Brunero 2012

3 Lack of tim

e

"Consistency of sessions and regular attendees at sessions were also pointed out as Lim

itations"; Each clinical area attem

pted to influence this as best as was practical, w

ith nurse unit mangers

replacing clinical staff mem

bers on occasions of need, although this was not alw

ays possible. There w

as mention of a lack of support from

senior nurses, even though there was inclusion of

senior nursing staff in the project development”

"To reduce the impact on lost clinical tim

e, the nurse unit managers took a clinical

role on the wards during the CS sessions to allow

more staff to attend the CS

session" Consider introducing CS sessions "in a period when the staffing profile of

most areas w

as high"

Buus 2011

96 Lack of tim

e

"Staff worked shift w

ork, and only a very small proportion of staff m

embers w

ould prioritize supervision enough to participate on a day off or in the shift adjacent to a w

ork shift. The recreational effect of having tim

e off duty was valued as m

ore important than clinical

supervision". High, everyday workloads hindered participation in scheduled supervision as staff

prioritized their clinical tasks. Paradoxically, it was so stressful for staff to find tim

e for clinical supervision that they often prioritized to finish their everyday w

ork “W

ell, you are a little torn about it. I know, w

ith my head, that it is very im

portant we have

supervision. You go and it’s been healthy and you speak about it afterwards. U

sually you gain som

ething, but if we are only four at w

ork and everything is in flames, I start thinking that w

e need to cancel. It is so annoying and you have been frustrated about it and think: ‘That dam

n supervision’. There is no tim

e for it; three persons stand in the corridor and want to talk and you

still haven’t done this or that. So the sensible thing would be to do it, but your feelings say: ‘But

this is chaos’. We try if w

e can do it, but have to cancel now and then. (Respondent 14)”

Chilvers 2009

10 Lack of tim

e "Tim

e comm

itment required seen as a barrier to CS" ‘the w

ard is too busy for me to leave’ and ‘I

have not completed m

y paperwork’”.

“Ward pressures either due to shifts or caseloads should not be excuses for non-

attendance. Finances were allocated to allow

additional staff to be on shift to cover the nurses’ absences (com

monly know

n as ‘backfill’) while at clinical supervision”.

Cox 2009

58 Lack of tim

e Cox refers to this as "tem

poral restrictions such as ‘difficulties with tim

e’, and ‘having to rush’"

Cross 2010

11 Lack of tim

e "Key barriers to im

plementing CS on a hospital w

ard are time (Cleary &

Freeman, 2005; Cole,

2002; Stevenson, 2005; William

s et al., 2005). Various issues relating to the unpredictable nature of patient care and w

ith rotating staff rosters mean that CS is not view

ed as a priority."

“The team m

eeting room on the w

ard was agreed to be the m

ost convenient location for CS and it w

as booked ahead for this purpose. Consideration had been given to utilising space aw

ay from the w

ard but it was felt that this w

ould make it

more difficult for staff to attend. As the participants w

ere senior mem

bers of staff, and therefore usually in charge of the w

ard, it was assum

ed that CS would be

better supported by more junior m

embers of staff if their seniors w

ere easily available in case of em

ergency. The NU

M agreed to cover the w

ard during the absence of the AN

UM

s and the sessions were held at a tim

e the NU

M could be

available”.

64 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

“Sessions were held for one hour, and coincided w

ith the double staffing that occurred betw

een shift changeovers so that ANU

Ms from

the morning and

afternoon shifts could attend. With a rotating roster m

ost ANU

Ms w

ould have the opportunity to attend sessions. Arrangem

ents were m

ade so that ANU

Ms w

ho w

ere not working could attend CS in their ow

n time, if they w

ished, and reclaim the

time in lieu. AN

UM

s also have days set aside for managem

ent purposes and where

these coincided with CS this w

ould offer a further opportunity to attend”. “Ground rules: em

phasised by the supervisor that although the sessions offered an opportunity to speak about frustrations associated w

ith work, it w

as to be hoped that they w

ould not become grum

bling sessions. The supervisor took responsibility to point out to the AN

UM

s (henceforth known as the supervisees) if this w

as occurring. Aside from

this no other guidelines were given. Interruptions w

ere m

inimal and related to w

ard issues that could not be deferred”.

Davis 2012

59 Lack of tim

e

“Three who did not receive clinical supervision, the reasons given w

ere that they did not know

about clinical supervision, could not find a group to join, did not have a supervisor or workload

was too dem

anding” “M

aking time for clinical supervision w

as expressed as a negative aspect as a result of workload

constraints and the process itself being time consum

ing. This correlates with sim

ilar discoveries by Johns (2003). Taking tim

e out from w

ork to attend is also identified as an area where

practitioners express feelings of guilt at leaving patients and their colleagues”.

Daw

son 2013

83 Lack of tim

e "How

atson-Jones (2003) suggests that clinical supervision is often underused because of m

isinterpretation, problems w

ith organizational endorsement and supervisory

relationships, and lack of funding or time”

Daw

son 2012

84 Lack of tim

e

"results suggest that supervisees perceived CS as time consum

ing, with the tim

e demands

increasing the perception that work pressures interfered w

ith CS. Edwards et al. found that

when nurses struggled to find tim

e for supervision, the level of emotional exhaustion and

depersonalisation (as measured by the M

BS) was higher"

Deery 2005

60 Lack of tim

e "W

e were doing som

ething that seemed as if it w

as going to encroach on our time (y ) it w

as hard at tim

es to see how w

e could possibly benefit from this [clinical supervision], other than

more w

ork, more com

mitm

ent and more hassle. (Interview

8)"

Edw

ards 2005 &

2006

94, 106 Lack of tim

e

"Finding time for clinical supervision sessions m

ay indeed be problematic (Butterw

orth et al. 1997). Findings from

previous studies have indicated that this could be because of workload,

staff shortages and Trust reorganizations (Gilmore 2001). Edw

ards et al. (2003) found that when

CMHN

s struggled to find time for supervision sessions then levels of reported em

otional exhaustion as m

easured by the Maslach Burnout Inventory w

ere higher"

65 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Evans 2015

14 Lack of tim

e

“Protected time for reflection should be prioritised by practitioners, m

anagers and the organisation”

Girling 2009

15 Lack of tim

e “Staff w

ere enthusiastic but expressed concerns about the time and resource im

plications for care”

"Champions som

etimes attended on their days off, for w

hich they were given tim

e off instead"

Turner 2005

105 Lack of tim

e "Tim

e was seen to be very lim

ited and thus meetings w

ere difficult to organise and also the time

within them

pressured, neither were there any established ground rules”

W

hite 2008

75 Lack of tim

e "Difficult to m

ake time to attend"

White

and W

instanley (2009 &

2010) 23,

77-81

Lack of time

“Other im

pediments included interruptions during CS sessions, lateness and other com

peting dem

ands on the supervisor’s and supervisee’s clinical time and other in-service

training activity. “W

ard workload; increasing the pressures on the group, as others subtly try and m

ake us feel guilty for still running the group. (4M

4) Competing needs for staff tim

e; e.g. increased acuity and poor treatm

ent options. Patients under-medicated, leaving staff to resort to archaic m

ethods, e.g. regular take-dow

ns and seclusion. Increased staff burnout, due to increased bullying from

medical staff, overtim

e and regular incidents as per previous. Senior experienced staff continue to avoid CS sessions. Staff’s ‘fear of retribution’ if attend and disclose inform

ation which m

ay be ‘used against them

’ by Managem

ent. (8M3 &

4)”. “Busy w

ard . . . can be only one or two perm

anent staff on a shift. Nursing staff are too tired to

come in on their day-off for CS. O

ur NU

M left the service and m

any permanent staff have also

left. The ward has been extrem

ely acute and often there is only one or two perm

anent staff on the shift, m

aking it difficult to get enough nurses to attend a session. Acuity of ward m

aking staff just w

ant to work and go hom

e; not interested. One Supervisor cancelled sessions last m

inute and staff w

ere disappointed and decided the thing was flaky. H

aven’t been able to get consistence groups; so poor consistency. (17M

2/4)”

Bailey 2014

5 Location

“Neutral location gives an even footing for m

embers, no-one’s territory.”; “This has

been a beautiful opportunity, not linked to workplace.”; “Com

ing out here from

town is part of the separation of w

ork/home – ‘like respite’, a ‘retreat’.”; “Feels like

a serious venue where serious things happen.”

66 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Brunero 2012

3 Location

"Accessing the physical space to have the sessions w

as of concern to some areas.

For those areas, where m

eeting space was difficult to access, negotiations w

ith other w

ard areas to acquire meeting room

s were arranged"

Edw

ards 2005 &

2006

94, 106 Location

"Another factor that appears to impede successful im

plementation of clinical supervision include

inappropriate conditions, such as a lack of suitable accomm

odation in clinical areas, or holding m

eetings too close to units, which increased the likelihood of being interrupted (Gilm

ore 2001)."

"Location of session had an effect on the effectiveness of clinical supervision. Those supervisees w

hose sessions were held aw

ay from the w

orkplace had higher overall scores on the M

CSS. The scores for trust/rapport and improved care/skills, and

reflection significantly improved if the sessions w

ere held away from

the w

orkplace." Supervisee feels more supported w

hilst reflecting on complex clinical

experiences and feels that clinical supervision positively affects the delivery of care and im

provement in skills w

hen conducted away from

the workplace

Girling 2009

15 Location

"difficulty finding appropriate venue for their supervisory sessions”. "Availability and suitability of venues in w

hich supervision can take place will

therefore be monitored"

Abbott 2006

53 Location

"Specific arrangements (tim

e and place) inconvenient"

White

and W

instanley (2009 &

2010) 23,

77-81

Managing the

staffing roster

“Set against these examples of early positive experience, how

ever, many of the substantive

issues raised by trainees about their post-course implem

entation experience, were portents of

difficult experience thereafter. The most challenging event that faced the m

ajority of trainees back in their hom

e locations, almost w

ithout exception, was the establishm

ent of a staff duty roster schedule w

hich took cognizance of the innovative CS arrangements. That is; trainees w

ere im

mediately exercised by the need to ensure that their neophyte supervisees w

ould be listed on the roster to w

ork together on the same shift, as the date set for the CS session. This w

as found easier to achieve w

hen the trainee also had personal responsibility for designing the staff duty roster. O

ften, however, this w

as not so and trainees were required to negotiate synchronized

dates with a third party. Here, too, this w

as easier to achieve when the third party (usually their

manager) w

as sympathetic to the CS endeavour, as evidenced above. W

hen this was not so,

considerable tensions were created and the roster-setter becam

e the sole de facto arbiter of the entire CS im

plementation program

me”.

“The process has been slowed initially by M

iddle Managem

ent being less than eager to respond and take responsibility for rostering appropriately and assisting, etc. (5M

3)” “Frustration w

ith time availability. I generally com

e in on my day-off. Tim

e changed by the NU

M

at the last minute for staff. The usual intrigue w

ith booking rooms booked and confirm

ed. Getting there, finding room

s locked. Time w

asted waiting for security to open room

. (24M2/5)”

67 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Chilvers 2009

10 M

andatory attendance?

“Second most com

mon question w

as ‘do I have to attend?’. Although the sessions are not m

andatory; staff are strongly advised to attend. The only exceptions for non-attendance are planned annual leave and sickness”

Long 2014

91 M

andatory CS

“Adoption on all wards of m

ultidisciplinary and mandatory group supervision

sessions on a weekly basis w

ith a view to all staff being involved for at least one

meeting per m

onth. While there are significant pros and cons regarding group CS

(Bond & Holland 2010), it is seen here as part of a process of culture change that is

supported by managem

ent as one element of m

eeting professional and organizational requirem

ents”.

Abbott 2006

53 M

ode of delivery

"One or tw

o would prefer individual clinical supervision"

Cross 2010

11 M

ode of delivery

"More cost-effective and efficient than one-on-one supervision in term

s of reducing the tim

e nurses spend away from

the busy clinical environment and direct

patient care. ….respondents w

ho participate in group sessions rate the advice and support provided by the supervisor as m

ore effective than those who receive one-

on-one supervision"

Edw

ards 2005 &

2006

94, 106

Mode of

delivery

Winstanley (2000) also reported that supervisees found it easier to find tim

e for sessions in a group situation, as there w

as less demand on staff to interrupt their

work schedule for individual sessions

Livni 2012

17 M

ode of delivery

[supervisory relationship] "May take longer to form

in group conditions, often hampered by

logistical issues as well as group m

embership issues"

"Alliance was m

ore strongly related to outcomes in individual versus group

supervision conditions suggests that effective relationships are more readily

formed in individual supervision conditions"

Bergdahl 2011

7 M

ode of delivery

"Appreciated the sm

all number of participants in the group"

Brunero 2012

3 M

ode of delivery

“Open group m

odel was used firstly from

a pragmatic point of view

. Accessing nursing staff from

busy clinical areas on rotating rosters proved a challenge and too difficult for a closed group option. An open group is said to effect group dynam

ics such as ‘trust’ (16) but it was felt that the

only way to achieve reasonable attendance w

as to have an open group format. The open group

format here w

as reported by mem

bers to impair the functioning of the group and its ability to

build cohesion and trust”.

"Group supervision was chosen over individual as it w

as the most pragm

atic of options given the size and volum

e of nurses within clinical areas. The collaborative

exchange of ideas, which group CS w

ould effect was perceived as an im

portant conduit for the critical thinking, w

hich CS would facilitate"

68 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Davis 2012

59 M

ode of delivery

“Disadvantages of one-to-one: supervisee can restrict the extent of their development by

censoring what is disclosed and it prom

otes introverted thinking”

Turner 2011

19 M

odel of supervision

[Criticism levelled at Proctor’s m

odel] “is regarding the lack of guidance around the interactions required to deliver the m

odel (Sloan, 2006)”

Abbott 2006

53 M

odel of supervision

"Model of clinical supervision appears to be m

ore about “containment” than about m

aking practice safe."

“Model being used am

ong comm

unity nursing staff appears to be primarily

‘restorative’ (Proctor, 2001). Staff spoke of ‘time out’ and of a chance to ‘de-stress’

far more often than they did of other benefits”.

O

'Connell 2011

104 Planning and organisation

“An hour-long TCS was offered on a w

eekly basis to accomm

odate rotating rosters and conducted in a staff m

eeting room on the w

ard to maxim

ize convenience for staff. It took place during the 2.5-hr “double staffing” period that occurred at the m

orning to afternoon nursing shift changeover, where the crossover betw

een the tw

o shifts meant that there w

ere sufficient staff to cover the floor while colleagues

are otherwise engaged”.

Taylor 2009

69 Planning and organisation

“Factors that influence clinical supervision, including: • Agreeing the length, frequency and location of sessions. • Skilled facilitation and planning the session. • Setting clear goals and objectives. • W

orking in partnership involving reflection in a supportive environment”.

W

allbank 2011

73 Attendance

“A significant observation early in the process was the num

ber of missed or altered

appointments that the cohort appeared to need in order to receive supervision. Several of the

professional did not attend their appointments w

ith explanation or made contact a few

minutes

prior to the session in order to cancel it. This behaviour appeared to be the professionals' way of

coping with the dem

and that were placed on them

”.

“High degree of flexibility on behalf of the supervisor”

Abbott 2006

53 Poor com

munication

Did not realise "innovation was up and running"

Bergdahl 2011

7 Poor com

munication

Other external barriers m

entioned were "lack of tim

e, comm

unication and resources"

69 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Gonge 2010

24 Shift w

ork

"Results reveal a diminishing tendency for staff to participate in clinical supervision if they w

ork evening shift com

pared to day shift, and even more so if they w

ork night shift. Straight forward

explanation to this finding was that all the clinical supervision sessions w

ere conducted during day shift, constraining staff w

orking evening and night shift from turning up w

hen they were off

duty."

"Work shift also affected participation, and offering only staff w

orking day shift access to supervision w

ithin working hours should be avoided"

O

'Connell 2011

104 Staff rosters

“Finding time to participate in TCS. They found it difficult to attend the sessions on m

any occasions because of the unpredictable and hectic nature of their w

ork. Some staff com

mented

that attending TCS made it difficult to com

plete other routine tasks, and they were concerned

about this issue. Staff suggested that it might be w

orthwhile to rotate the days on w

hich TCS is conducted to enable different staff to attend”.

Cox 2009

58 Supervisor availability

“Supervisor having other roles aside from trial, therefore at tim

es not being able to locate them

that day if a difficulty arises ⁄ questions to ask…. This highlighted individual circum

stances, the view

s of supervisees and the importance of the supervisory relationship”

Girling 2009

15 Supervisory contracts

"Despite insistence during training of the importance to the practice supervision policy of

contracts, 31 percent of respondents had not signed one"

Cross 2012

12 Tim

e

“dedicated time for reflection”

Abbott 2006

53 Tim

e CS scheduled

"Specific arrangements (tim

e and place) inconvenient"

Gonge 2015

2 W

ork-shift &

duty roster "O

rganizational obstacles such as work shifts and duty roster (Buus et al. 2010, 2011)"

Gonge 2010

24 W

orkplace factors

“Olofsson (2005), psychiatric nurses reported that their participation in a reflective activity w

as dependent on the priority given to participation by the w

ard manager, how

difficult it was to

find time for supervision, and personal feelings of guilt about leaving the w

ard during clinical supervision”.

"In line with this result, it could be recom

mended that future research should pay

more attention to the influence of w

orkplace factors (e.g., workload) (Sloan, 2006),

on nurses’ participation in clinical supervision."

Individual (personal) factors

Bailey 2014

5

Building constructive relationships

“Sharing with others has assisted m

e to realize that others have similar difficulties

with particular scenarios, w

hich thus allows m

e to proceed with confidence as this

is then normalized. A little black hum

our goes a long way rather than perceiving the

lack of enjoyment in particular types of presentation as m

y personal failing”; “This

70 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

normalisation then m

akes it easier to deal with that scenario”

• “Being able to discuss difficult situations has elicited comm

onalities in scenarios m

any people find challenging rather than seeing it as a failure” • “Hearing of others’ struggles show

s me the im

pact of difficult cases or scenarios on their feelings and thoughts has assisted m

e to acknowledge and process in a

more tim

ely and reflective ways som

e of my ow

n and assisted me to interact w

ith m

y work colleagues around these things”

• “Peer supervision enables me to connect w

ith other professionals and to learn from

them and for them

to learn from m

e. We all have different experiences in our

work and it helps by broadening understanding in a supportive environm

ent” • “Collegiality, professionalism

and good humour of group participants”

Gonge 2010

24

Cognitive dem

ands constrains participation

"Cognitive demands (including keeping an eye on things, decision m

aking, and remem

bering) and “tim

e managem

ent” (e.g., nurses have less time for ordinary w

ork tasks). This is in accordance w

ith what O

lofsson (2005) reported as influencing participation in reflection groups am

ong psychiatric nurses working in hospital w

ards. In a busy ward w

ith many things to do and

remem

ber, one may easily lose track of things. Cognitively, a good grasp of the situation is

required to allocate time for participation in clinical supervision."

Bow

ers 2007

8 Collegiality ('team

-spirit')

CS sessions were seen as "facilitating team

working"

Brink 2012

9 Collegiality ('team

-spirit') "Cam

araderie could be a threat to good, safe care”

“Collegiality leads to greater trust in colleagues, especially in difficult situations” . "Collegial exchange of experience leads to increased self-aw

areness and positive professional developm

ent, ( ‘‘. . .I have been working for the shortest tim

e among

the people here and I really need to develop my com

petence in order to be able to handle various situations in prehospital care . . .’’; ‘‘. . .O

ut there, you have to make

a lot of decisions on your own and it is not alw

ays easy. So you need a forum,

where you can get confirm

ation of whether or not you acted correctly in the

situation..)”

M

cKenna 2010

89 Cultural supervision

“Importance of addressing cultural supervision specifically for health professionals

who are M

aori. The purpose of this latter supervision, by Maori for M

aori, is to build know

ledge of Maori cultural values, attitudes, and behaviours; provide a

supportive context to manage com

plex cultural issues; and to ensure safe practice and culturally appropriate behaviour (How

ard, Burns, & W

aitoki, 2007; Walsh-

Tapiata & W

ebster, 2004). Similarly, w

here practitioners of other non-dominant

ethnic groups are working in m

ainstream organisations, cultural supervision is

recomm

ended where there is a m

atching of the supervisee and the supervisor’s ethnic group”

71 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Rice 2007

85 Fear of engaging

“Apprehension and fear of engaging in clinical supervision among m

ental health nurses”

Bow

ers 2007

8 Feedback

"Critically challenging each other’s practice: supportive peer dynamics in the forum

may inhibit

how m

uch mem

bers risk critically challenging one another’s practice and “even with the

guidance of an outside facilitator, district nurses receiving group clinical supervision found it difficult to raise questions about each other’s out-dated practice because discussions w

ould becom

e too personalized”

Ayres 2014

55

Feedback and m

onitoring perform

ance

“Supervisees’ expectations of advice and feedback from a positive and directive supervisor w

ere largely unm

et"

Cross 2010

11 Getting w

ith the program

me'

“But we actually m

anaged to talk in several different sessions and we all m

anaged to com

e out with the sam

e strategy for how w

e were going to deal w

ith it together and w

e applied what w

e’d been talking about. And it just made the situation so

much better. W

e were all sort of on the sam

e program w

ith it”.

Turner 2005

105 Group dynam

ics

"Not being supportive to each other, often not listening or valuing w

hat each other were

saying…quieter personalities felt they w

ere not heard at all. Meetings often added to our stress

levels due to the time com

mitm

ent, structure of the meetings, group interaction and lack of

direction". "The group used its usual problem solving approach. Its application in this situation

meant w

e all wanted to talk over each other, offering advice and solutions of that the individual

presenting the situation for discussion felt attacked rather than supported. The whole

experience was very distressing"

Cross 2010

11 Shared experience

“Hearing that other people are having the same concerns, or hearing other

concerns that you hadn’t thought of that are issues for other people too. We got to

know each other a bit m

ore and know w

hat each other are thinking a little bit.” “And you can bounce off each other as w

ell. A few tim

es I’ve gone in and there’s been som

ething that’s niggling at me and it’s nice to know

I’m not the only one that

it’s annoying… And you know

that it’s confidential”

Cerinus 2005

56

Need tim

e for supervisory relationship to develop

“Knowing each other w

as not sufficient in itself to ease the establishment of a

clinical supervision relationship. It was a com

bination of knowing, com

fort and trust that m

ade the difference. ‘But I would say, in the second, third and fourth m

eeting w

e’ve been a lot better, we’ve m

anaged to talk about things that were very

confidential, and things that I was surprised at her discussing w

ith me, to be honest

with you. So I w

as quite pleased because at least then I knew that she w

as trusting.’ (Holly) positive experiences of a clinical supervision relationship developing over tim

e. With that developm

ent, at least one-third of participants experienced greater feelings of trust w

ith their partner, contributing to a growth in the range and depth

of issues raised during clinical supervision sessions. ‘As the relationship developed

72 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

it became easier to discuss a broader range of issues. I think this is because w

e had built up m

ore trust and confidence in the partnership.’ (Frances)”

Bailey 2014

5

Netw

orking reduces isolation

“I value comm

itments and I saw

it as an opportunity to network w

ith other professionals”; “Peer supervision enables m

e to connect with other professional

and to learn from them

and for them to learn from

me. W

e all have different experiences in our w

ork and it helps by broadening understanding in a supportive environm

ent”; “The great opportunity to learn from m

ore experienced social w

orkers. The networking opportunity it provides”

“The opportunity to learn from social w

orkers working in different fields of w

ork to w

hat I am currently in”

“Yes it is beneficial to understand that others have similar concerns and difficulties

in providing the service in a rural area where resources are lacking. It helps one to

feel less isolated and the sense of connectedness means that I can engage in

professional dialogue to gain others’ perspective, refer to others if a particular area is outside of m

y expertise and experience, and to feel supported by others”; “U

seful for application to supervision and support. Useful to observe relatedness

and rapport establishment. U

seful in reflecting on other professionals’ lines of questions and challenges. U

seful to hear how supervision interventions, direction

of questioning were perceived and w

hat was found to be useful”;

“I love how the m

any different ideas/advice can arise and how w

elcome one feels

in the group”

Hall and Cox 2009

88

Other support

available

“Participants reported that they were unsure how

to differentiate between the Know

ledge and Skills Fram

ework (DoH 2004; Kleiser &

Cox 2008), annual appraisal, rotational reviews and

clinical supervision and how to use each effectively. Three different participants reported that

they were already w

ell supported within the physiotherapy departm

ent and questioned the need for clinical supervision. Interview

ee A: …there’s actually quite a lot of avenues, certainly for the rotational staff because

we get an appraisal every four m

onths, we get a halfw

ay…appraisal so that’s every tw

o months.

We get our KSF…

I think there’s quite a lot out there already”.

Abbott 2006

53 Participation and ow

nership

"One suggested that a course on how

to participate in clinical supervision would be

useful"; “close links with both front line staff and m

anagers: this was necessary to

ensure that they felt some ow

nership for the process and were w

illing to participate”

Bailey 2014

5 Participation and ow

nership

“You had to choose to do it-self-determination in choosing to participate in this

group – very positive and there is an open valuing of participation because of free choice”

73 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Bow

ers 2007

8 Participation and ow

nership

"Establishing well-defined ground rules for their internally facilitated group clinical

supervision sessions created the environment necessary for effective clinical

support. Mem

bers of the staff nurse forum also stated that establishing explicit

ground rules brought the all important elem

ents of safety, impartiality, support,

respect and trust to their sessions”

Brunero 2012

3 Participation and ow

nership

"Involving participants in the developmental phase of the project enabled them

to take ow

nership and responsibility for their part in its process (27)" "A forum

where staff can discuss any topic and form

ulate a plan of action therefore giving them

ownership of w

hat happens on their ward”

Evans 2015

14 Participation and ow

nership

“Period of consultation, review and engagem

ent enabled us to develop a menu of

options supported by an organisational guideline that was “ow

ned” by all clinical staff (Box 2)”

Girling 2009

15 Participation and ow

nership

"Workshops to raise aw

areness of practice supervision among staff w

ere held so that staff had early opportunities to express their view

s" "Cham

pions have also kept up the profile of practice supervision by including it on the agenda on team

meetings, for exam

ple, and during the induction of new staff

mem

bers"

Gonge 2015

2 Participation and ow

nership

"Appeared promising to create space – physically and psychologically – allow

ing staff open and critical reflection on their supervision inspiring them

to take ow

nership of how the supervision could be better adapted to their individual needs

in the specific workplace (cf. Cleary et al. 2010)"

Gonge 2011

109 Participation and ow

nership

"Most im

portant factor associated with experienced effectiveness of clinical

supervision was participation in supervision. The num

ber of ‘sessions of clinical supervision attended w

ithin the last 6 months’ w

as significantly associated with

more positive experiences of ‘trust/rapport’ (0.22), ‘supervisor advice/support’

(0.16), ‘improved care/skills’ (0.17), ‘reflection’ (0.14)"

Turner 2011

19 Participation and ow

nership

“Overall it seem

s that maintaining a client focus, using an agenda and being

engaged in regular clinical supervision has impact not just on the individual but the

wider team

in the snowballing of clinical supervision from

one to another”

Cox 2009

58

Perception of supervision qualities

“Qualities agreed as bad supervision w

ere: administrative issues dom

inating supervision; hierarchical supervision and supervisees having a passive role”.

“The qualities agreed by the respondents as good supervision were: respect and

empathy; consideration of challenging issues; supportive and interactive; creates a

space for thinking; using a range of methods; inform

ation giving, modelling,

observation, problem solving focus on concrete exam

ples from supervisee’s clinical

activities; have clear boundaries set; being available and accessible; giving advice on crisis m

anagement; dem

onstration of specific skills; clear, constructive, sensitive w

ritten and verbal feedback; give suggestions for im

provement and have a clear contract at outset”.

74 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Long 2014

91 Personal factors

“The former include a fear of change and a lack of confidence, know

ledge skills or understanding (Bush 2005). These m

ay result in the lack of a comm

on understanding of the nature or purpose of CS (How

atson-Jones 2003), a failure to see the need for CS (Bush 2005), ad hoc im

plementation and delivery m

odels that do not correspond with the realities of m

ental health nursing environm

ents (Cleary & Freem

an 2005). "Factors that might prevent individuals from

raising issues in CS include supervisor issues (n = 24), supervisee issues (n = 13), staff shortages (n = 13), tim

e issues (n = 11) and work pressures (n = 5). Issues relating to supervisors include

lack of trust, unapproachable supervisor, fear of victimization, thinking their supervisor w

ill not listen, feeling uncom

fortable with supervisor and confidentiality issues. Supervisee issues

include feeling embarrassed about needs, personal problem

s, fear of issues reflecting badly on them

, peer pressure, not wanting to cause conflict and not practising w

ithin the job role"

Cross 2010

11

Positive and constructive feedback

“He’s very constructive in what he says. He’s not saying you shouldn’t do this, you

shouldn’t do that. He just gives you different ways of perhaps approaching som

e things, especially to do w

ith some staff m

embers, their attitudes or w

hatever. He’s very good w

ith that”; “I suppose in our role, w

e have to be role models for the rest of the staff. But hey,

we w

ant to bitch and moan as m

uch as everyone else does…The one session that I

did, we had a discussion about one particular patient that w

e had who frustrated

the hell out of everyone on the ward, including [the supervisor] because he w

as involved as w

ell, so it was good to know

that we all feel the sam

e way and w

e actually got som

e very positive feedback from [the supervisor] about that particular

patient and how w

e dealt with it …

We w

ere getting praise from other areas of the

hospital… So it w

as really nice to get some really positive, constructive feedback,

particularly from [the supervisor]”

“It’s a good way to offload stresses, w

orries, and share your thoughts and especially if you’re in w

ith one of the others they can give you feedback on maybe

how to deal w

ith something m

ore difficult. But also positive things” “And helping you not to go hom

e with all these things in your head w

here you’re thinking ‘I’ve had such a bad day today’. You can offload it so I’ve alw

ays gone hom

e after the clinical supervision with a lot m

ore, you know, all the w

eight’s relieved. You’re clearer headed.”

Cox 2009

58 Pow

er im

balance

"A potential conflict and power im

balance of competency rating and supervision roles w

as identified by tw

o respondents. This highlighted the possibility of a perception of power relations

at work that had not been considered (or specifically identified) by other respondents. O

ne respondent stated for exam

ple that her …supervisor is in position as ‘boss’ and quality control

monitor as w

ell as supervisor; power im

balance is a barrier to open and honest comm

unication at tim

es"

Rice 2007

85

Problems w

ith supervisory relationships

“Howatson-Jones (2003) suggests that clinical supervision is often underused because of

misinterpretation, problem

s with organizational endorsem

ent and supervisory relationships, and lack of funding or tim

e.”

75 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Buus 2013

4 Psychosocial needs

“Psychosocial need for trust during sessions (inside the supervision space)” "Participants w

ere very reluctant voicing critical opinions about their usual supervisor and sim

ilar dynamics w

ere observed between participants and the m

oderators. This could indicate that som

e participants experienced the usual supervision relationship as an authoritative one and w

ere hesitant in voicing their own thoughts and opinions".

Gonge 2010

24 Social support

“Increased social support facilitates participation”; “Support from colleagues

facilitated engagement in supervision. In a study of clinical supervision am

ong nurses in general, Teasdale et al. (2001) suggested that high levels of perceived support w

as associated with participation, especially am

ong low-grade hospital

based nurses. Gonge suggests social support helps nursing staff resolve any anxiety and resistance tow

ards the self-disclosure needed to engage in the reflective process of clinical supervision."

Boland 2010

92

Supervision "not a one-w

ay' relationship

“However, participants stressed that both parties needed to understand that the supervision

process is not a one-way process that is ‘given’ to supervisees”

“Supervisees must be active in this process and recognise that they need to m

ake an effort to increase their skill base and professional capabilities”.

Resistance to change/m

otivation

Long 2014

91 M

otivation “W

idespread lack of knowledge about CS (resisting forces)”.

"Significant number of qualified staff are m

otivated by and feel positive about CS (pushing)" a key part of the new

strategy has been to coordinate motivated and

qualified staff to play a major role in the overall com

munication strategy to inform

and m

otivate other staff”.

Turner 2011

19 M

otivation “Sustainable change in practice requires leadership, project m

anagement and change

managem

ent. Generally speaking, individuals have different levels of motivation for change and

some have resistance”

“Study attempted to m

anage this resistance by early engagement w

ith the staff team

and to use change models in order to be as inclusive as possible but also to

use the ‘authority’ within w

ard leadership to make change happen”

Davis 2012

59 M

otivation for CS

“No one gave ‘recom

mendation by professional body’ as their rationale. Involvem

ent in clinical supervision sessions”

“Learning from their experiences and im

provements to patient care w

ere the main

motivators for starting clinical supervision”

Abbott 2006

53 Resistance to change

"Some tendencies to m

oan for moaning’s sake, and a few

longer-serving mem

bers of staff rem

ained cynical (‘we’ve seen it all before’)"

Best 2014

82 Resistance to change

"Supervisee resistance characterized by the fear that clinical supervision will identify failures and

inadequate practices (Butterworth, Bell, &

Jackson, 2008), threaten confidentiality, and increase stress levels for the w

orker (Butterworth et al., 2008; Cottrell, 2002; Hyrkas, Appelqvist-

Schmidlechner, &

Paunonen-Ilmonen, 2002; Jones, 2001, 2003). Authors have also expressed

concerns that supervision can result in a loss of independence and work autonom

y, the feeling of being scrutinized, and leaving oneself open to criticism

for a lack of enthusiasm on the part of

the worker (Ask &

Roche, 2005)"

76 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Buus 2011

96 Resistance to change

"Cleary and Freeman (2005) observed that staff m

embers exercised a passive resistance tow

ards clinical supervision because of the lack of relevance and resources."

Davis 2012

59 Resistance to change

“Ward m

anagers held high expectations of the benefits of clinical supervision, they remained

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

as a passing fad, a form

of managerial control and som

e feared loss of autonomy. These perceptions echo the

literature related to resistance to change and barriers to effective implem

entation”

Deery 2005

60 Resistance to change

"Clinical supervision is also resisted in some areas of nursing because it is perceived as another

managem

ent monitoring tool (Rolfe et al., 2001 )"

"We w

ere doing something that seem

ed as if it was going to encroach on our tim

e (y ) it was

hard at times to see how

we could possibly benefit from

this [clinical supervision], other than m

ore work, m

ore comm

itment and m

ore hassle. (Interview 8)"

Gonge 2015

2 Resistance to change

"Individual barriers such as defensiveness and reluctance (Wright 2012) "

Gonge 2010

24 Resistance to change

"Such individual characteristics may lead to open or passive resistance tow

ard mutual reflection

and participation in clinical supervision” "Subjective individual characteristics m

ay be associated with reluctance to disclose personal

experiences and attitudes, anxiety, and the activation of psychological defence mechanism

s (Cleary &

Freeman, 2005; Jones, 2006)."

"Summ

ing up, more attention should be given to investigating how

the objective and subjective individual characteristics of nursing staff m

ay influence participation in clinical supervision."

White

and W

instanley (2009 &

2010) 23,

77-81

Resistance to change

“Start-up difficulties were not alleviated in settings w

here the prevailing managem

ent culture w

as unsupportive, obstructive or, on occasion, frankly hostile to the local CS innovation. White

et al. (1998) has previously theorized that points of resistance were acted out not only by

individuals who doubted the value of CS, but also by those w

ho did not have any such doubts and w

ere driven by the need to control the possible impact that CS m

ight have on the established culture of an organization, in w

hich they occupy privileged positions”. “Despite the charade of being otherw

ise, I feel Managem

ent is being obtuse; evidenced by just how

long it has taken our groups to get up and running. (4M3)”

Feedback from N

UM

that some staff stated they thought CS w

asn’t any good. On investigation,

discovered these were staff m

embers w

ho weren’t actually going to CS. (24M

4)” “The rum

ours I hear are that it is a way for M

anagement to check on staff, despite assurances

to the contrary. On the grapevine, I have heard nurses are suspicious that the supervision is

‘managem

ent’ checking up on them. (15M

2/5)”

Session content/structure

Abbott 2006

53 Session content and structure

"Some felt that the sessions had been ‘just grum

bling’ rather than constructive, and because of staff shortages and re- organization w

ithin the PCT, sessions had focused too often on crisis m

anagement rather than looking at clinical issues"

77 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Bailey 2014

5 Session content and structure

“Clarity and adherence to the agreed structure and m

ethod for working w

ithin the group are pivotal"

Bergdahl 2011

7 Session content and structure

Participants described "useful narratives that were used to facilitate supervision

sessions and the use of a “structure-thinking tool”. "Linking the narratives to nursing research and theory the participants realized that m

any of the problems they experienced in practice have been discussed in nursing

science". “You structure your thoughts differently because of this supervision. I can m

ore easily understand what’s im

portant in a situation”; ‘The structure of the analysis m

akes everything clearer. It enables us to get straight what help is needed

to progress. It feels great to have a structure to guide our thinking”. “Sim

plicity of the three concepts in the thinking tool seems to have been beneficial,

with the participants internalizing the thinking tool, w

hich seemed to help them

reflect on, and analyse, m

ore complex narratives”.

“Simplicity could be the reason that som

e of the participants have reported that they use the thinking tool in their daily practice. U

se of the thinking tool, links to nursing research and ethical theories gave the nurses a new

way to approach a

problem, and refram

e their experiences”. "W

hole group appreciated the theoretical discussions with links to practice,

especially when the supervisor succeeded in m

aking a link between the narratives

and the results of nursing research and theory: ‘I think it was alm

ost magical at

times…

".

Brink 2012

9 Session content and structure

"Structure creates security and participation... I realise that the structure is needed as a base for our group sessions because it helps people to think carefully and reflect on im

portant issues...’’ ‘‘... I think it w

as good that it was structured and that people had to think before

they said anything. It is the structure that helps you express your feelings and what

you have been thinking about...”

Cookson 2014

57 Session content and structure

(See Box 1 and 2, p16)

Kuipers 2013

93 Session content and structure

"A qualitative study exploring the preferences of paraprofessionals to a similar group-based

approach, all of the participants clearly stated a preference for a spontaneous model, and

rejected a formally structured or evaluated approach to group-based supervision.13";

Conversely, there have been suggestions that informal approaches to clinical supervision are not

constructive, and may perpetuate existing problem

s. In terms of outcom

es, a recent study docum

ented numerous positive learning and com

petence outcomes from

the implem

entation of a structured m

odel of clinical supervision for nurses, which used contracts and clear rules about

"PGS groups that used a degree of documentation, the tools provided in the PGS

training, and some evaluation of the groups rated their groups m

ore highly than those groups that did not; w

ell established ground rules and that their confidentiality w

as respected"

78 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

engagement and participation."

Boland 2010

92

Structure content and supervision

“Conflict or confusion regarding generic and discipline specific supervision was identified as

often a problem by 26%

of the participants”

Long 2014

91

Structure content and supervision

“Key ingredients for the good practice of CS for nurses include the use of formal contracts

between supervisee and supervisor (Proctor 1988b), a distinction betw

een managerial

and CS (UKCC 1996), voluntary participation (Cutcliffe &

Proctor 1998) and a focus on the job content of the supervisee (M

arrow et al. 1997)”.

Taylor 2009

69

Structure content and supervision

“During supervision, scrutiny of the individuals’ practice by the team had been perceived by

practitioners as an unsupportive and negative experience”

“Volunteers were asked to present a vignette of a case that presented a challenge

because there were exceptionally com

plex needs or because the practitioner was

unable to see a clear way forw

ard. The facilitators met the presenting clinician to

establish aims and objectives and planned the session, ensuring tim

e for focused discussion. U

sing various techniques, tools and methods learned on the ten ES C

training, such as breaking into pairs or working in sm

all groups with staff from

other disciplines, w

ith whom

they would not norm

ally work, the team

engaged in focused activities. This w

as important for sharing know

ledge and expertise, and learning about each other’s values and perceptions. Breaking the large team

into pairs allow

ed for those less confident in expressing their views in the large group to

contribute more. Follow

ing a period for discussion the team reconvened to provide

feedback on their deliberations”. “Form

at allowed for focused, constructive discussion that w

as forward looking,

rather than criticising previous practice. This method had other benefits such as

confirming to clinicians that their concerns w

ere legitimate, for exam

ple when

team m

embers acknow

ledge that some cases w

ere too complex to m

anage alone, and providing support for the decision to refer to specialist services on m

ainland U

K”.

Terminology

Cross 2010

11 Term

inology

"Terminology issues: “reservations about the term

‘clinical supervision’ and preferred to consider it ‘reflective practice’. "The w

ord ‘supervision’; ‘I just can’t get over that! Sorry, I still have a problem w

ith it!’; I think research w

ise, clinical supervision seems to be the nam

e that it’s known by. But clinical

supervision sounds like somebody w

atching over you; ‘They could call it clinical support program

, because that actually tells you what it’s for”.

Daw

son 2013

83 Term

inology “Definition of clinical supervision w

as also identified as problematic w

ith confusion about what

clinical supervision was and how

it related to other supervisory approaches”

79 M

ain theme

Author Year

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Girling 2009

15 Term

inology “Lack of clarity of how

clinical supervision is defined (Bush 2005, Shanley and Stevenson 2006), w

hich may contribute to w

hat Cottrell (2002) describes as 'suspicion, mutiny and tokenism

' about the supervision process"

To ensure staff were kept up to date w

ith progress, the facilitator circulated quarterly new

sletters. The identification of 'champions' is seen as key to success to

projects…their com

mitm

ent and enthusiasm has been critical to the project's

success". "The cham

pions have continued to make them

selves available to colleagues to answ

er questions and ensure information about supervision has been easily

available”.

Hall and Cox 2009

88 Term

inology

“For some physiotherapists the term

‘clinical supervision’ was associated w

ith undergraduate training and this m

isunderstanding affected participants’ effective use of the process. Interview

ee D: We’ve said about the nam

e…m

aybe that needs to be changed. Especially for new

juniors coming in…

especially if you’ve come straight from

university, you assume clinical

supervisor…is som

eone that’s going to help you with your clinical stuff…

”

M

cKenna 2010

89 Term

inology “Clinical supervision focuses on clinical practice, yet nurses m

ay be involved in academic,

managem

ent, and leadership roles. Thus, we favour ‘professional supervision’ to project the

value of supervision beyond clinically specific roles (Hamer et al., 2006)”

O

'Connell 2011

18 Term

inology

“Staff suggested that those people who w

ould perhaps benefit most from

participating in TCS are less inclined to voluntarily engage in it. This insight from

staff in the current study is consistent w

ith the literature (Butterworth, Bell, Jackson, &

Pajnkihar, 2008; White &

W

instanley, 2010). This may be related to concern over the term

supervision and a comm

on m

isconception that TCS is a performance m

anagement exercise or only required for staff w

ho are experiencing specific problem

s (Cheater & Hale, 2001; Cross et al., 2010)”

“It may be useful to consider renam

ing CS to “peer support” or “clinical team

support.”

W

allbank 2012

72, 97 Term

inology "An um

brella term w

ith little clarity around function and purpose (Gonge and Buus, 2011)”

Chilvers 2009

10 Tim

e CS scheduled

“Timing for the m

eetings appeared to be crucial if full attendance at these sessions was to be

met”

80 APPEN

DIX 6: Table 16: Summ

ary of barriers and facilitators to clinical supervision as reported by supervisors

Main them

e Author (Year)

Sub-themes

Barrier (Evidence) Facilitator (Evidence)

Attitude/Culture Ayres 2014

55 N

egative supervision culture “Supervisors and supervisees perceived supervision to be a relatively unproductive experience”

O

'Connell 2011

18 The pivotal role of the clinical supervisor

“…

independent nature of the supervisors and their distance from the w

ard and m

anagerial issues. They felt that this independence and objectivity allowed them

to provide a different perspective and offer “fresh insights” and solutions”.

Daw

son 2013

49 Value

"Most supervisors expressed a sense of enjoym

ent of participating in a supervisory relationship and m

any of the participants described CS as being challenging and rew

arding, ‘quite rewarding – connects m

e to younger therapists and what’s going on –

keeps me up to speed.’ The opportunity to reflect on clinical practice for both the

supervisor and supervisee was described as ‘exciting’ and ‘helping the unm

otivated supervisee’".

M

cKenna 2010

110 Value

“Resistance of some nursing staff to engage in supervision is w

ell articulated in the literature although the reasons for it poorly understood (Hines-M

artin & Robinson, 2006; Kelly, Long,

& M

cKenna, 2001; Walsh et al., 2003). It is difficult to determ

ine the degree of resistance in the N

ew Zealand context due to the

difficulty in accessing adequate records of professional supervision com

pliancy rates”.

Rice 2007

85 Value

“Ability to satisfy themselves that the Code of Professional Conduct, guidelines and

standards are adhered to on an on going basis by practitioners. It supports the principles of clinical governance. Clinical supervision im

proves practice which leads to

increased safe care delivery which results in reduced com

plaints. Furthermore, it greatly

assists managers to m

eet statutory quality requirements, and ensure accountability…

It also is a key safeguard for m

anagers who support practitioners to review

and continually reassess their professional actions”.

Boundaries Boland 2010

92 Clarify roles

“Found that these participants reported feeling drained by their supervisees w

hile training and supervision for these supervisors w

as also lacking, particularly for younger workers. The subtle

differences between supervisors and supervisees in reporting

methods of supervision perhaps reflects the focus group’s view

of confusion regarding the nature of supervision and the need for com

munication betw

een those in a supervisory relationship and industry standards for training and delivery of this practice”

“… Ideally, supervisors should receive training regarding supervision delivery in order to

have a clear understanding of their role in the supervisory relationship”.

81

Abbott 2006

53 Clarifying roles and responsibilities

"Scope and boundaries of the role would need to be m

ade extremely clear"; “the staff

involved (supervisors, supervisees and managers) w

ere defined in guidelines that form

ed part of the clinical supervision policy, and contracts were signed by m

anagers to ensure that staff w

ould have protected time for clinical supervision”.

Alleyne 2007

54 Clarifying roles and responsibilities

“Professional nature of the supervisory relationship, where boundaries are clearly

defined, was recognized by all the participants as an im

portant element in creating a

climate w

here concerns could be freely explored and creative approaches to personal and professional developm

ent identified and acted upon”

Daw

son 2013

83 Line m

anagement

“There appeared to be confusion as to how CS m

ay differ from

line managem

ent and mentoring; participants described the

effect of this as, ‘blurring and it’s confusing people now’ and that

CS seems to be trying to cover all bases – som

etimes about line

managem

ent, but also mentoring, and m

aking sure that the job gets done appropriately”

Abbott 2006

53 Line m

anagers as supervisors

"Facilitators in managerial positions should not run groups w

hich included any of the staff they m

anaged"

Cookson 2014

57 Line m

anagers as supervisors

“Difficulty in implem

enting ‘best practice’ in clinical supervision, especially regarding the lack of distinction betw

een clinical supervision and line m

anagement supervision, and the

implications this has on confidentiality, content and effectiveness

of clinical supervision (Rice et al 2007, Sines and McN

ally 2007, Lavallette et al 2011, Sloan and Grant 2012). Evidence indicates that m

anagers may believe that supervision carried out by other

individuals might erode and dim

inish their own pow

er, control and authority”.

Daw

son 2012

84 Line m

anagers as supervisors "Clinical supervision by the line m

anager may also negatively

affect the quality of the CS and thereby patient care, as staff may

guard information so as not to reveal deficiencies."

Turner 2011

19 Line m

anagers as supervisors

“One respondent noted (in response to norm

ative questions) that ‘I alw

ays felt I was forced into this area too soon’. O

ne may

interpret this in a number of w

ays, for example the desire, as line

managers/supervisors, to ensure standard issues w

ere discussed, or the desire to pass through each area of Proctor’s m

odel within

the supervision session”.

W

allbank 2012

72, 97 Line m

anagers as supervisors

"Access to clinical supervision that remained separate to

administrative or m

anagerial supervision was rated as significant

to comm

unity staff. Additionally, having a supervisors who w

as not the individual's line m

anager was also key to achieving a

successful supervisor/supervisee relationship".

82

Dawson

201383

Purpose of CS unclear

“Theme of understanding CS reflected the participants’

knowledge of CS and its purpose. Participants suggested CS

‘facilitates development of reasoning skills, know

ledge and ensures quality of care. There is also a bit of line m

anagement and

mentoring involved, advising staff for them

selves and not necessarily for the organisation’. Another participant stated that the purpose of CS is to assist ‘junior staff in clinical reasoning, w

orkplace ethics, workplace processes’ and also that CS has ‘a

support role, problem solving role and longer term

developm

ent’.”

Cutcliffe 2006

87 Role duality: conflict of interest

“There is a tendency for those in senior roles to focus on perform

ance and action rather than exploring the subtleties of process; there is the potential for m

aterial offered during supervision to be used in a disciplinary m

anner; there is the tendency to focus on m

anagement (norm

ative) issues as the m

ajor agenda; and there is a confusion caused by the duality of supervisory and m

anagerial roles”

Bailey 2014

5 Rotating supervisor/facilitator role

“Everyone having a chance to experience supervisee and supervisor roles has been positive”; “Group structure – no obvious pecking order”; “This group’s level playing field – a really lovely thing”

Bow

ers 2007

8 Rotating supervisor/facilitator role

"M

ore comfortable discussing issues w

ith their peers"

Turner 2011

19 W

ho should be a supervisor? “W

ho should be the supervisor...literature argues for and against line m

anagers, but if they are clinical leaders who are experienced

and have a clinical focus, then should this be such a problem?”

“One w

ay we achieved this w

as through a tiered rather than pyramidal structure of

clinical supervision whereby the w

ard manager (for exam

ple) supervised all grades of staff ensuring that no group/band did not have this level of support. It w

as in hindsight that w

e noticed the importance of this, ensuring the w

hole team w

as involved and that no staff w

ere supervised by the least experienced staff”.

Choice Daw

son 2013

83 Choice of w

ho was in the

supervisory relationship

“The allocation to a supervisory relationship and supervisee com

mitm

ent were also reported as perceived barriers to CS.

Collegial relations were identified as an additional challenge for

some supervisors, ‘content area of supervision m

ay be challenging, but the m

ain difficulty is when there is an

interpersonal relationship as a colleague with the supervisee’“.

Knowledge and

Skills Chilvers 2009

10 Clinical supervision for supervisors?

“Clinical supervision provided by an external source”

83

Lynch 2008

64-67 Identifying the need

“… w

hat we had been trying to find for quite som

e time [w

as] how

to support nurses in the clinical practice…[w

e] were all

confronted with exactly the sam

e problems and w

e were at our

wits end about w

hat to do… W

e had tried a range of things like education, clinical nurse educators on the unit, those sorts of things, but it w

asn’t meeting our needs”

Brunero 2012

3 Lack of standardised training

"Training of facilitators in CS has been the subject of attention in the literature. W

hilst the facilitators had attended various training program

mes, there are little in the w

ay of standardised CS facilitator training courses in Australia".

“Developing champions of CS w

ithin the workplace and m

aintaining a system of

developing and supporting these people would help contribute to the on going viability

of CS”

Long 2014

91 N

eed for education and training “N

eed for education and training for both supervisors and supervisees w

as a significant theme”.

“Mandatory 1-day training sessions w

ere undertaken with senior trained staff w

ho w

ould act as ‘culture carriers’ and cascade learning towards HCAs. Training focused on

the concept and practice of supervision and was intended to w

iden perspectives regarding the range of activities that qualified as supervision”.

Chilvers 2009

10 Q

ualifications and Education See Table 1, p14

Chilvers 2009

10 Skills and know

ledge of supervisor See Table 1, p14

Bergdahl 2011

7 Supervisors expertise and know

ledge

“The supervisor herself was an experienced nurse: ‘supervisor’s know

ledge and background w

ere considered important by the participants, ("the supervisor is w

ell read in nursing theory and has a solid background in the profession itself; that is the strength of this group supervision")“

Davis 2012

59 Training

“Development of supervision skills w

as identified as a problem for

25% of supervisors”.

“Six stated they had undertaken a 2-day supervisors training programm

e, one had attended a half-day training event and, in addition, tw

o had completed the CPD m

odule in Teaching and Assessing”

Girling 2009

15 Training

"Poor attendance due to conflicting staff priorities, however, it

was decided to hold no m

ore of these meetings"

"Training of enough supervisors was deem

ed crucial and it was agreed that the

maxim

um num

ber of supervisees needed for each full-time m

ember should be three. In

response to requests by supervisors, a continuing educational day for supervisors was

also held with the follow

ing aims: to learn m

ore about key skills; to practice supervisor skills; to equip supervisors w

ith additional resources to enhance their supervisor skills”

Herbert 2006

86 Training

“Supervision tends to be a reactive process with m

inimal tim

e investm

ent. Majority of current rehabilitation supervisors have

received no training in clinical supervision” “A training program

me should be im

plemented”

84

Wallbank

201173

Training

"Training professionals to deliver supervision need not be a costly exercise and the m

odel introduced to the cohort was designed to cascade to other staff" A know

ledge, Skills and Com

petency framew

ork has been developed for supervisors and supervisees (see Box 1).

M

ilne 2010

68 Training

"Little information to guide us as to the m

ost effective ways of

training supervisors’" supervision has also been poorly served by research (Ellis &

Ladany, 1997), which com

pounds the problem, as

the absence of adequate research and development (R&

D) means

that there is an inadequate basis on which to design and evaluate

the much-needed supervisor training. In sum

mary, as W

atkins (1997) has put it, ‘som

ething does not compute’ (p. 604)”

Logistics Brunero 2012

"Pool of facilitators"

"Developing the skills of a pool of facilitators over a period of time w

ould enable the on going im

provement of CS. …

argue that resources need to be invested in supervisor education and nursing staff need to be encouraged to start w

orking in both supervisor and supervisee roles, because of the positive effects on job satisfaction and quality of care"

Chilvers 2009

10 "Pool of facilitators"

“Main difficulties encountered w

as the insufficient number of

clinical supervisors”

M

cKenna 2010

89 Adm

inistrative responsibilities

“Most difficult function to integrate is the adm

inistrative responsibilities. For instance, there is the need for professional supervision to assist in m

eeting the administrative responsibility

to determine com

petency. Yet the survey found little evidence of professional supervisors inform

ing annual performance review

s. There is a need for supervisors’ reports or attendance at such review

s. This role would need to be transparent w

ith procedural checks and balances that m

aintain fairness; otherwise the danger

is that supervisees perceive the supervision process as a front for the exercise of institutional pow

er (Hewson, 1999)”.

Boland 2010

92 Availability of supervisee

“Thirty percent of respondents indicated that the availability of their supervisor/supervisee has also often caused difficulty in the receipt/delivery of supervision”

Daw

son 2012

84 Availability of supervisor

"The location of the health service in a regional area may have

affected the availability of suitable supervisors for selection, as travel or telecom

muting w

ith external supervision may be m

ore com

plicated than allocating local supervisors"

Daw

son 2013

83 Docum

entation Docum

entation was presented as a “barrier based on the

perception that it was unw

ieldy and that it could be used against the supervisee”.

85

Ayres 2014

55 Im

portance of good documentation

"Comprehensive guideline for the supervision of occupational therapy staff set out the

service expectations of supervision: a definition, the principles for effective supervision, contract setting, recording, duration and frequency, issues of confidentiality, the content of supervision (including clinical, adm

inistrative tasks /managem

ent, professional developm

ent and training, and support), and the benefits of supervision to both the organization and the individual."

Boland 2010

92 Lack of tim

e “Forty four percent of all respondents indicated that a high case load has often caused difficulty in the delivery/ receipt of supervision in the past tw

o years”.

M

cKenna 2010

89 Lack of tim

e

"Professional supervisors were m

ore vocal in indicting the barriers to the provision of professional supervision, w

hich needed to be addressed. The predom

inant theme for over half of the supervisor

respondents was tim

e constraint. Supervisors with clinical

obligations expressed difficulty balancing their supervision role w

ith their clinical caseload. In some instances caseload

requirements m

eant they could not fulfil their supervisory com

mitm

ents. It was felt that these constraints needed to be

addressed by managem

ent in the services concerned"

Davis 2012

59 M

ode of delivery

“Group clinical supervision is a challenge for supervisors. The study show

ed that group supervision did not foster feelings of togetherness w

ithin the team. As a result of the group clinical

supervision sessions teams w

ere engaging in more joint decision-

making, how

ever, conflicts amongst team

mem

bers were also

reported. Although comm

unication was found to have becom

e m

ore open amongst team

mem

bers, honesty varied between

teams. This led to increased tensions in som

e teams”.

Abbot 2006

53 Staff turn-around and loss of supervisors/facilitators

“There were also w

orries that clinical supervision might be

allowed to lapse, given the departure of som

e trained supervisors and the project lead (AS), and a proposed organizational re-structuring”; “Som

e groups have had to self-facilitate because their supervisor has left, and there w

ere fears that groups left to fend for them

selves may becom

e too “cosy”.

Daw

son 2013

83 Tim

e to deliver CS “The them

e of barriers to CS included the difficulty in finding tim

e to deliver CS, ‘I can’t shoe horn all this extra workload

without im

pacting on my clinical load’.

Personal factors M

cKenna 2010

89 Cultural supervision

“Maori nurses indicate the need for cultural and professional

supervision to occur simultaneously as culture and practice are

intertwined”

“Importance of addressing cultural supervision specifically for health professionals w

ho are M

aori. The purpose of this latter supervision, by Maori for M

aori, is to build know

ledge of Maori cultural values, attitudes, and behaviours; provide a supportive

context to manage com

plex cultural issues; and to ensure safe practice and culturally appropriate behaviour (How

ard, Burns, & W

aitoki, 2007; Walsh-Tapiata &

Webster,

2004). Similarly, w

here practitioners of other non dominant ethnic groups are w

orking

86

in mainstream

organisations, cultural supervision is recomm

ended where there is a

matching of the supervisee and the supervisor’s ethnic group”

Daw

son 2013

83 Feedback

“Differing expectations as to who should deliver critical

feedback to the supervisee. Participants suggested provision of critical feedback w

as not part of CS and felt that it should be provided by the discipline clinical m

anager. Comm

ents on critical feedback included, ‘goes directly to the clinical m

anager’ and ‘I tend to avoid it’. Participants described feeling ‘throw

n in’ and experiencing difficulty w

hen providing aspects of CS, particularly w

hen a manager has asked for an issue to be addressed.

The theme of perceived im

provements through CS provided

insight into the benefits of CS”.

Ayres 2014

55 Feedback and m

onitoring perform

ance "Supervisors found supervision difficult and felt uncom

fortable giving feedback or m

onitoring performance"

Chilvers 2009

10 Personal qualities

See Table 1, p14 “Authors have developed an essentials and desirables list for person specification of a CS”

Rice 2007

85 Problem

s with supervisory

relationships

“Howatson-Jones (2003) suggests that clinical supervision is often

underused because of misinterpretation, problem

s with

organizational endorsement and supervisory relationships, and

lack of funding or time”.

Resistance to change/m

otivation Rice 2007

85 CS im

proves staff motivation levels

“Improves staff m

orale and motivation; practitioners review

clinical practice and re-evaluate their professional and personal developm

ent. Clinical supervision also provides opportunities to m

anage conflict and to examine resolution strategies”.

Resistance to change/m

otivation M

cKenna 2010

89 Resistance to change

“The unavailability and unwillingness of som

e mental health and

addiction nurses to engage in professional supervision. Reference w

as made to resistance by som

e nurses to engage in supervision: ‘nurses do not alw

ays come from

a culture of supervision. Their attendance is often less regular than counsellors or psychologists’. “This issue w

as highlighted in supervisory relationships in which

the nurse had been directed to undertake clinical supervision. Directed supervision included the supervision of new

graduates in post-graduate m

ental health programm

es; ‘fitness to practice’ determ

inations for staff experiencing mental health issues; and

the use of professional supervision as a ‘resolution tool in perform

ance managem

ent issues’. Most supervisors thought this

process was useful; how

ever there was a degree of am

bivalence expressed in undertaking directed supervision, given a perceived resentfulness on the part of supervisees w

ho lacked the

87

motivation to engage.

Service users input M

cKenna 2010

89 Service user and cultural input into professional supervision

“Very few services involved service users in aspects of

professional supervision. ‘I have a hesitation [of consumer

involvement] in actual supervision. W

e need to carefully think about issues of professional developm

ent and this is clinical supervision w

ith a high degree of trust and openness in order to deal w

ith issues that are very sensitive, especially if the person is exploring issues of transference or counter transference’.”

Session content and structure

Chilvers 2009

10 Session content and structure

"Supervisors w

ere encouraged to prepare their group sessions as far in advance as possible to give people an opportunity to arrange w

orking rotas and other appointm

ents to maxim

ize attendance"

Support Abbott 2006

53 O

n-going support

"Internal facilitators would need on-going support"

Girling 2009

15 Support for supervisors

"It was clear that the supervisors required on-going support to enable them

to reflect on their supervisory practice and to deepen their learning. Therefore one support groups for supervisors w

as set up at each hospice…the facilitator w

as available for anyone w

ho wanted one-to-one support"

88 APPEN

DIX 7: Table 17: Summ

ary of barriers and facilitators to clinical supervision reported at a health systems level

Authors (Year)

Theme

Barriers (Evidence) Facilitators (Evidence)

Abbot 2006

53

Accessibility of care: Location and time CS scheduled

"Specific arrangem

ents (time and place) inconvenient"

Human resources:

Staff turn-around and loss of supervisors/facilitators

“There were also w

orries that clinical supervision might be allow

ed to lapse, given the departure of som

e trained supervisors and the project lead (AS), and a proposed organizational re-structuring”; “‘Som

e groups have had to self-facilitate because their supervisor has left, and there w

ere fears that groups left to fend for themselves m

ay become too

“cosy”

Ayres 2014

55

Accessibility of care: Finding time

Regarded as an "operational m

anagement rather than a process issue"

Financial resources: seen as an “investment” in CS

“The Trust occupational therapy service has invested in profession-specific clinical supervision training and guidance, as w

ell as supporting staff to access external clinical supervision training.”

Value and benefit of CS to the organisation

“The value of [CS] w

as publicly endorsed by the College of Occupational

Therapists”

Bailey 2014

5 Accessibility of care: Location

Provision of a suitable location for CS seen as really important (“university

provided a seminar room

on campus and access to academ

ic and practice literature for discussion. “Evidence from

these data indicates that considerable capital for the university w

as accrued through this support. (“The campus’ status as neutral but

supportive territory") Bergdahl 2011

7 Financial resources: lack of investm

ent

Other external barriers m

entioned were "lack of tim

e, comm

unication and resources"

Brunero 2012

3

Accessibility of care: Location

Areas identified as potential barriers to the success of CS were ..., physical

space to have the sessions”

Accessibility of care: Lack of time

Areas identified as potential barriers to the success of CS were nurses’ tim

e aw

ay from clinical dem

ands"

Financial resources: Costs of training

Areas identified, as potential barriers to the success of CS were "potential on

going training costs.”

“Maintenance of a m

odel of CS is dependent on a number of factors. Cost

estimates of providing peer group CS is estim

ated at 1% of an annual nursing

salary (34). [White E, W

instanley J. Cost and resource implications of clinical

supervision in nursing: an Australia perspective. J Manage 2006; 14: 628– 36.]

This would seem

a reasonable cost for the potential benefits arising from CS"

Financial resources: U

se of external facilitators and availability of facilitators

Both Bond and Holland (23) and Clifton (24) recomm

ended training by external consultants w

ho are not seen to be part of the current context or w

ith the philosophies of structures of the organisation

89 Authors (Year)

Theme

Barriers (Evidence) Facilitators (Evidence)

Chilvers 2009

10

Financial resources: Additional costs for extra staff to cover shifts

"In the original costing of the proposal, m

onies were identified to backfill staff

time aw

ay from the w

ard to attend the sessions. This was an im

portant elem

ent if staff were to attend during w

orking hours" Financial resources: Group supervision preferred

“This m

odel has smaller financial im

plications”

Financial resources: seen as an “investment” in CS

(“Economic benefit”)

Key benefits of CS “can result in an im

pact on staff turnover and risk m

anagement w

ith obvious economic benefits to the organization”

Kulpers 2013

93 Hum

an resources: CS value

"From

an organizational point of view, professional support and clinical

supervision are seen as important strategies for im

proving clinical governance, m

aximizing service quality, and even enhancing recruitm

ent and retention"

Lynch 2008

64-67

Financial resources: credibility

“Financial support was essential. O

ne participant described how she w

as able to be influential in this process…

I sit in a very unique position. I am not

blowing m

y own trum

pet but I have got incredible credibility with senior

managem

ent and so if I back a project it usually gets through… I had to w

rite a business proposal to executive and say w

hy we needed such a big financial

comm

itment…

they thought that if I believed that it would m

ake a change to nurses then they w

ould fund it, so…the w

ay you get to that point in an organisation is just credibility”.

Financial resources: viable business plan

CS must be seen as financially viable. "Butterw

orth and Faugier (1992) argued that gaining support for resources is fundam

ental to acceptance of clinical supervision and successful im

plementation. They advocate that organizations

must have evidence to support the notion that clinical supervision is effective

and financially viable. Therefore, as a part of implem

entation, organizations should ensure that clinical supervision is m

onitored in order to dem

onstrate its effectiveness. Areas to monitor include: staff sickness and

other absences, increases in creative and innovative practice and expressed consum

er satisfaction".

Human resources: under-resourced

“Senior managem

ent, which included a num

ber of senior nurses in the mental

health programm

e, was concerned about the serious hum

an resource issues such as: an increase in w

ork cover and sick leave, and difficulties with

recruitment and retention. In addition to the above hum

an resource data, they also conducted a needs analysis via qualitative surveys and focus groups in tw

o teams; the results of w

hich highlighted a sense of dissatisfaction with

work loads, team

dynamics, and m

anagement. The culture and environm

ent in this organization w

ere described by one participant as: . . . angry, hostile …

.demoralized and anti-m

anagement. Another participant stated that in

general staff felt: . . . unsupported . . . There weren’t system

s in place to keep them

safe”.

Rice 2007

85 Financial resources

"Howatson-Jones (2003) suggests that clinical supervision is often underused

because of misinterpretation, problem

s with organizational endorsem

ent and supervisory relationships, and lack of funding or tim

e. All respondents em

phasized the need for adequate financial resource for clinical supervision to w

ork properly.

“They estimated that each practitioner w

ould need between 1.5 and 2 h

protected time per m

onth for this process. Suggested training comm

itments

are outlined in Table 1”.

90 Authors (Year)

Theme

Barriers (Evidence) Facilitators (Evidence)

Human resources:

Lack of resources and time

“The results of the survey suggested that managers and educationalists w

ere positive about clinical supervision. It w

as felt that there was less enthusiasm

am

ong hard-pressed clinical staff that were facing regular alterations in staff

numbers and expertise”.

Turner 2011

19, 70 Financial resources: cost benefit

“Estimate that “clinical supervision is only one hour, som

etimes out of 150

hours of clinical work” but describe it as a “costly venture. If there are 30

staff in a team all supervising each other for one hour a m

onth on an average grade of band 5 (for the sake of calculation), then the cost for one w

ard w

ould be £10,173 (using NHS AfC pay scales for 2011/12)”.

“As an investment this does not seem

expensive if there are direct correlations w

ith clinical standards, stress (and as a result, reduced sickness) and continuity of care, so as an investm

ent it has to be time w

ell spent”.

White and

Winstanley

(2009 &

2010) 23, 77-81

Human resources: burden and cost

“In the absence of making appropriate logistical arrangem

ents, the perfunctory introduction of CS w

as regarded as an additional activity for staff to accom

modate. This w

as reported to stretch human resources to breaking

point and created predictable inter-staff tensions”

“Where the introduction of CS w

as regarded as an integral professional nursing activity, especially in settings w

here the demonstrable buy-in from

Managers

was apparent, the new

enterprise was not burdened by additional costs and

also benefitted from the secondary gain of positive role m

odelling”

91 APPEN

DIX 8: Table 18: Summ

ary of barriers and facilitators to implem

entation of clinical supervision reported at a social and political level

Authors (Year)

Theme

Barriers (Evidence) Facilitators (Evidence)

Abbot 2006

53 O

rganisational restructuring

“There were also w

orries that clinical supervision might be allow

ed to lapse, given the departure of som

e trained supervisors and the project lead (AS), and a proposed organizational re-structuring”

Ayres 2014

55

Legislation or regulations

“Legal and professional requirements for clinical supervision”

Bailey 2014

5 Credibility/Value of CS at social and political level

CS seen as “critical im

portance and a mandatory requirem

ent”

Cerinus 2005

56 Credibility/Value of CS at social and political level

M

ultiple policy documents published. These include: (Departm

ent of Health, 1993; UKCC, 1996;

UKCC 2001

Cookson 2014

57 Value and benefit of CS to the organisation

“Recom

mended in professional guidance from

individual professional bodies including the Health Professions Council (2008), the N

ursing and Midw

ifery Council (2006), the Chartered Society of Physiotherapy (2005) and the College of O

ccupational Therapy (2007)”

Cox 2009

58

Credibility/Value of CS at social and political level

“Many professional and national policy docum

ents (Chartered Society of Physiotherapy 2000; Departm

ent of Health 2000, 2003, 2004) have recomm

ended that CPD and reflective practice are em

bedded within clinical supervision. It is therefore im

portant to recognize the part clinical supervision plays in fulfilling the tw

o agendas of professional development and professional

regulation (Kleiser & Cox 2008)”

Long 2014

91

Credibility/Value of CS at social and political level

‘A Vision for the Future’ [N

HS Managem

ent Executive (NHSM

E) 1993], supervision became an

established part of nursing practice.. The United Kingdom

Council for Nurses, M

idwives and Health

Visitors (UKCC 1996)

Lynch 2008

64-67

Absence of government

policy

Absence of government policy

Organisational

restructuring and changing political landscape

“Num

ber of significant challenges…such as deinstitutionalization and m

ainstreaming.

“Changes in hospital ownership, from

public to private, and then recently back to a public hospital…

throughout these changes there were a num

ber of sensitive human resources

issues such as demotions of staff, redundancies, and m

ajor changes in the managem

ent structure. A senior nurse described these changes: “. . . there w

as evidence of horizontal violence and cannibalism

in a number of the units/team

s”