An integrated approach to introducing and maintaining supervision: The 4S model

Waskett, C (2009) Nursing Times 105:17, 24-26
This article is reproduced with kind permission of the Editor.

Abstract

Though strongly recommended as a matter of clinical governance for nurses and other health service professionals, supervision is not yet universally and robustly in place. This article outlines the 4S model — structure, skills, support and sustainability. This first puts in place a managerial structure, then teaches a solution-focused approach and skills to volunteer supervisors, as well as ensuring proper support and sustainability.

Introduction

Clinical supervision is rather like the Cheshire cat in Alice in Wonderland; it smiles broadly from on high, but fades in and out of view. Some departments, services or teams use supervision regularly. Others mean to — or once meant to — but somehow the practice has dwindled or faded.

The literature is extensive and tends to focus on the supervisory pair or group, and the practice, evaluation or research into the practice of supervision itself (Hyrkas, et al 2006, Teasdale et al 2001; Driscoll, 2000; Jones, 1999; Bond and Holland, 1998; Butterworth and Faugier, 1992). This article takes a more systemic, four-stage view of embedding a supervision scheme into a trust or organisation.

All NHS clinicians should practice supervision. The NMC (2008) advice sheet on supervision stated: "Clinical supervision should be available to registered nurses throughout their careers so they can constantly evaluate and improve their contribution to the care of people". Other professional bodies, such as the Royal College of Speech and Language Therapists (2009) and the College of Radiographers (2003) have made similar statements.

Hill (2005) reported on a successful scheme offering supervision to the whole range of allied health professionals (AHPs) and healthcare scientists in Birmingham, and stated: "Clinical supervision is key to AHP professional practice". Hawkins and Shohet (2003) described a model favoured by university courses, aimed at all in the helping professions.

The practice is mandatory amongst counsellors, psychotherapists and psychologists, art, drama and music therapists among others. It is common, though not universal, in mental health services, and amongst occupational therapists.

Experience suggests that the regular supervision is more of an intention than a reality, often for very good reasons (Robinson, 2005). There are no clear guidelines to promote confidence in clinical supervision among hard-pressed managers, nor are there universally accepted definitions. Many managers and clinicians have vague and uncertain views of clinical supervision. Sweeney et al (2001) stated: "Although there is no lack of theoretical writing... the theories themselves have provided little guidance for ongoing research and practice. This has resulted in confusion..."

There is confusion with line management, clinical teaching, preceptorship, mentorship, policing, coaching and counselling. Some think it is a method of managing poor performance for a short period of time. I would argue that it is none of these things.

All clinicians should have regular line management and access to clinical advice from a more senior practitioner. These are different from supportive supervision (Table 1). A broad, simple definition of supervision might be:

"An off-line, career-long relationship (or serial relationships) offered to all staff at any level, in which the supervisee can talk regularly with another person/group, in confidence, about personal learning, development and progress as a professional practitioner. The aim of both supervisee and supervisor is to facilitate and encourage the supervisee's ongoing growth towards excellence in the practice of their profession."

So the challenge is to introduce a supervision scheme that is streamlined and practical, collaborative and effective, and one in which there is a comprehensible, robust structure, which staff find easy to use and keep using. There are very few schemes which take the whole system into account and these are inclined to be rigorous but cumbersome (RCN Institute, 2000).

Most importantly, any scheme should help both supervisors and supervisees to work more efficiently, feel more energised and learn together with joy from their working experiences and resourcefulness. It should ultimately benefit patients by helping clinicians to be more in touch with their own confidence, compassion, and pride in their work.

Anecdotal evidence suggests that efforts to establish supervision in many trusts have begun, and all too often ended, with training supervisors. These staff members, overworked and unsupported, have usually failed to deliver over time through no fault of their own.

However well trained, a supervisor or group of supervisors cannot work against a culture unused to the concept, without managerial support, structure and resources. Supervision schemes are most likely to succeed where they are planned and steps are taken in succession.

The "4S" model has four stages: structure, skills, support and sustainability.

Structure

Management commitment is needed first, to lay down a clear, comprehensible structure that will later support supervisors and supervisees.

The group leading on supervision should have the power to make decisions and the authority to make things happen. Their role is not to train as supervisors, unless they wish to, but to act as facilitators and guardians so that the scheme can grow and flourish.

They will need to agree on the definition of supervision and why they have decided on it. Once they have agreed, they can use their joint resourcefulness to implement their decisions.

Choices and dilemmas

Clinical supervision skills

Volunteers interested in practising as supervisors are invited to a two-day course on supervision skills.

A solution-focused approach is simple, collaborative and respectful while being easily understood by health service staff (Waskett, 2006). This model, while mainly used for counselling and psychotherapy supervision (O'Connell and Jones, 1997; Thomas, 1996; MacDonald, 2007) can be adapted very well to supportive supervision for health professionals.

Although simple, the approach needs discipline, self-awareness and lots of practice. Supervisors learn to be respectfully curious and realise they do not have to know any answers. This can be difficult for NHS staff, who have been trained to problem solve. The solution-focused approach is not a problem-solving model, but a solution building one — a subtle difference that takes time to understand.

On the other hand, most health service staff start from a good position as their training has given them people-skills, understanding around confidentiality issues, and common sense which stands them in good stead.

The potential supervisor learns communication skills to enable the supervisee to identify their own strengths and resources, look at how they want to use these to progress in their work, and use practical steps towards this goal. This approach has added value in that participants comment on its transferability to use with patients and in other situations (Macdonald, 2008; Burns, 2005). Supervisors also learn to manage the dual role of looking out for the wellbeing of patients, clients or families that supervisees may discuss in supervision, in addition to supervisees' wellbeing and progress.

Understanding boundaries

Supervisors need a sound understanding of boundary issues. These include confidentiality and many grey areas. It is also important to look at record-keeping, accountability and the relationships between supervisor, supervisee and line manager.

Participants leave the course with a clear idea of what they will be doing next. They are encouraged to read more around the model, enjoy their new learning, and relax into their roles as partners who are very much learning by doing. It is fine to make lots of mistakes. Transparency with partners is built into this model of work, with both learning together.

Support

Supervision is not an exercise in dull bureaucracy. It is hard work, demanding concentration and attention. It can be exciting, inspiring and even frightening.

Being a supervisor is a position of serious responsibility and obligation to the supervisee, their patients, and their organisations. Balancing these fairly, positively and non-judgementally, while being of help to the supervisee, asks much of these newly-trained people. After initial training, supervisors now have fragile, largely unpractised skills but they learn rapidly as they begin to work with supervisees.

The temptation will be to let self-discipline slip, to chat and eventually become didactic. It is extremely seductive for new supervisors to help supervisees by telling instead of asking. Supervisors need ongoing support to develop skills, learn from each other, troubleshoot, have a place to explore aspirations and uncertainties, and find inspiration. There are several ways to do this. Typically, supervisors will meet as a group regularly, perhaps quarterly. Supervisors must have their own ongoing supervision. The partners must agree that discussions involving supervisees must remain confidential unless both agree on formal action.

Sustainability

The working group will be planning for sustainability from the beginning to ensure there is detail on what managers will need to do to keep the scheme moving through the years and inevitable changes ahead.

Some essential elements are:

Conclusion

This model takes time to introduce and establish. Initially, it demands commitment, investment, training and hard work.

However, once the scheme is running it becomes routine. Using a clear structure backed by senior management, solution-focused skills training, and ongoing practice and support, the 4S is a simple yet effective and sustainable model of supervision.

Table 1: Some tasks of different methods to manage, teach and support the professional

Line Management/team leadershipClinical advice/teachingSupervision
Leading the team/serviceDemonstrating proceduresListening non-judgementally
Everyday management of the teamSuggesting reading materialDebriefing
Coaching and supporting team membersGiving informationAsking respectful questions about work
Performance managementActing as a role modelRecognising and appreciating supervisee's strengths and resources
AppraisalCreating learning opportunities in one to one informal or formal trainingHelping to establish supervisee's direction/progress towards excellence
Not confidential (as default position)Not confidentialConfidential (as default position)
AssessingEnabling reflection on thinking/feelings/actions
MarkingFacilitating forward movement in career

Box 1: Structure

  • Managers need to take control and offer structure and support for a supervision scheme
  • Structure, skills, support and sustainability should all be addressed in planning
  • Do not rush — allow time to set the scheme up robustly
  • Evaluation of the whole scheme is essential

Box 2: Practice

  • The purpose of supervision is to assist supervisees to work as effectively as possible
  • Supervisors should have a power-free relationship with supervisees
  • The solution-focused model of supervision is simple yet disciplined and respectful
  • Supervision for all clinicians should be career-long, not just for emergencies.

Practice points

  • Embedding supervision in an organisation needs preparation, planning, ongoing management and evaluation
  • Structure, skills, support and sustainability are all essential to a robust and lasting scheme
  • Supervision should be simple, disciplined and routine
  • The goal of supervision is to support and facilitate supervisees' increasing growth towards excellence.

References