Following the findings from three investigations into complaints from families relating to local midwifery supervision and regulation at University Hospitals of Morecambe Bay NHS Foundation Trust, the Parliamentary and Health Service Ombudsman (PHSO) identified weaknesses in the midwifery regulatory arrangements at a local level. The PHSO found that the cases demonstrated a conflict of the supervisory and regulatory roles of Supervisors of Midwives (SoMs) and published its report, Midwifery supervision and regulation: recommendations for change (PHSO, 2013). The PHSO found a structural flaw in the way midwifery combines investigation and support for midwives. In 2014, the Nursing and Midwifery Council (NMC) commissioned The King's Fund (2015) to undertake a review of the regulation of midwives across the UK. The NMC accepted the recommendations of the above reports, which were to remove the regulation currently in place for midwives through statutory supervision (NMC, 2015a). The NMC accepted the two principles identified in the reports: that midwifery supervision and regulation should be separated; and that the NMC should be in direct control of regulatory activity. Discussions are continuing as to how this should be achieved.
However, questions may be raised about what may be lost, and it seems reasonable to explore the value of retaining some aspects of supervision. One of these might be the annual supervisory review, which could be undertaken in a group format. This paper reviews worldwide literature and asks several questions about clinical supervision and group supervision in order to inform the debate.
What is clinical supervision?
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 of care in complex clinical situations' (Department of Health (DH), 1993). In 2007, a wide-ranging review of literature on clinical supervision published between 2001 and 2007 considered 92 articles in terms of ‘levels of engagement; the usefulness of clinical supervision as an educational and supportive device; ethical debate, personal and organisational challenges and effects on patient outcome and staffing disposition’ (Butterworth et al, 2008: 265) (Box 1).
|Clinical supervision as a supportive device has attracted more attention than any other. Most studies are self-reported, qualitative in method and suggest that clinical supervision and its processes confer benefit in many 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 development are vital to nurses, their practice and patient safety|
|At a time when such opportunities are being stripped from the working week and seen by some employers as unproductive, evidence seen here suggests entirely the opposite and strongly counters the prevailing view of this being ‘unproductive’ time. Employees who are supported and are allowed time to reflect and develop will make a significant contribution to patient wellbeing and safety, and employers bear a considerable responsibility in sustaining and developing this activity in their organisations|
|Literature giving accounts of ethical debates and the personal and organisational challenges for participants is interesting. There are those who declare the process to be a sinister imposition and others who see its properties to be almost akin to a ‘magic bullet’. It is neither, of course, but questions raised in the literature are right and proper|
|Discussions on tokenism and badly practised clinical supervision hold necessary lessons. There is evidence for the strength of clinical supervision but it is clear that it makes some clinicians uncomfortable|
Is clinical supervision needed?
Research suggests that good supervision is associated with job satisfaction, a reduction in staff turnover, an increase in critical thinking and improvements in reflective practice (Social Care Institute for Excellence (SCIE), 2013a; 2013b; 2013c).
In health care, following several high-profile cases—particularly that at Winterbourne View—the Care Quality Commission (CQC, 2013) published a comprehensive guidance document setting out how professionals and service providers should provide and support clinical supervision. The CQC seemed to be reflecting many of Butterworth et al's (2008) findings when it proposed the potential benefits of clinical supervision. It clearly identified that supervision is generally considered to complement, but be separate from, management processes that monitor and appraise staff performance (CQC, 2013). It does not state whether this should be on an individual or group basis, but the recommendation for supervision is clear.
The Welsh Government (2015) has also recently published a Green Paper, Our Health, Our Health Service. Chapter 3 of this Green Paper relates to clinical supervision and refers to the current processes in midwifery supervision, noting that there is no consistent approach to supervision for other non-medical health care staff in preparation for revalidation. It asks for views on such support, what models could be considered and whether legislation should be considered. This paper may contribute to these discussions.
The NMC is about to launch its revalidation model, which aims to improve public and professional confidence in health care practitioners' practice. The NMC (2015b) has stated that nurses and midwives should stay up to date in their professional practice. They need to develop new skills, keep informed on standards and understand the changing needs of the public they serve and their fellow health professionals. Revalidation provides nurses and midwives with the opportunity to reflect on their practice against the standards in the Code and demonstrate that they are ‘living’ these standards. For those nurses and midwives who are professionally isolated from their peers, the NMC says, revalidation will encourage them to engage in professional networks and discussions about their practice.
It therefore seems reasonable to suppose that clinical supervision, and in particular group supervision, might help to fulfill the aim of NMC registrants engaging in professional discussions about their practice.
What are the findings from research into group supervision?
Group supervision has been in use in mental health, clinical psychology and therapy contexts for many years (Paterson, 1966; Milne and Oliver, 2000; Taylor, 2013). More experienced supervisees have stated that their continued attendance of the group sessions confirmed their own expertise and helped to facilitate the development of others in the groups, which enhanced satisfaction.
Milne and Oliver's (2000) study was in the field of clinical psychology. They administered a questionnaire to a meeting of 73 clinical psychologists, supervisors, course tutors and service managers. They also interviewed 22 supervisors and undertook a national survey of clinical psychology courses, with 13 courses responding to the survey. The researchers stated that although no demographic data were collected, they were satisfied that a fairly representative sample of genders, seniority and specialities was included. They noted that supervision resulted in (Milne and Oliver, 2000: 301):
‘An increased diversity of ideas and observations, the capacity to recognise common problems or themes, and the opportunity to share work with peers and to receive collective support and wisdom.’
Group supervision is also thought to be a relatively natural format for people who work together, which contributes to professional socialisation and facilitates learning in a familiar setting (MacKenzie, 1990). Group members experience mutual support and share their common experiences while potentially solving complex problems. They may develop new behaviours, undertake skills training and increase communication and insight. The interaction of the group members is considered to be essential to the success of this kind of supervision (MacKenzie, 1990).
‘In a cash-strapped NHS, it is essential to consider the potential costs of clinical supervision… Costs are likely to be lower in group supervision than in one-to-one supervision’
Much research into group supervision has been undertaken in Scandinavia (Francke and de Graaff, 2012). Several papers relate to group supervision for GPs, reporting beneficial outcomes in terms of skills in dealing with patients (Nielsen et al, 2013) and satisfaction with continuing professional development (Tulinius and Hølge-Hazelton, 2010). A number of papers relate to group supervision in pre-registration programmes, and these generally report positive findings including increased patient attentiveness, empathy and insight (Holm et al, 1998); better preparation for demanding situations (Lindgren et al, 2005); and improved professionalism (Holmlund et al, 2010).
What about group supervision in midwifery?
There are few papers relating to group supervision in midwifery. However, in 2005, midwife researcher Ruth Deery offered findings from a qualitative study into midwifery group supervision in the North of England. Her action research study explored eight community midwives' thoughts about their support needs, and how they would wish to receive that support. As part of the study, the participating midwives planned and facilitated a group model of clinical supervision. The service was undergoing extensive reorganisation and Deery (2005) reported that organisational change and increased demands placed on midwives were having a detrimental effect on the process of clinical supervision, as well as on the midwives' relationships with each other and their clients. Deery (2005: 161) noted:
‘Pseudo-cohesion and resistance to change were key defence mechanisms used by the participating midwives… A large amount of published literature supported the existence of stress and burnout in midwifery, but no research addressed ways of alleviating this situation. Effective facilitation of midwifery support is needed, which can be met through support mechanisms such as (group) clinical supervision.’
In contrast, in a Scandinavian study, while the midwife participants had also recently been involved in structural reorganisation into ‘continuity of care’ teams, there were no such concerns about reorganisation and resistance, and group supervision was seen as a way of increasing professional competence (Severinsson et al, 2010).
In 2013, a UK paper reported on findings from group supervision that was set up in a London hospital as part of recommendations from the CQC following concerns about training and supervision of midwifery staff (Roseghini and Nipper, 2013). In 2011, it had been noted that approximately 19% of midwives in the hospital had never had a supervisory annual review. Group supervision was set up by the London Local Supervising Authority for the midwives who had not had their review. Eighty midwives attended groups, along with six to 14 colleagues, ranging from newly qualified midwives to those with over 20 years' experience. Nineteen midwives completed an evaluation and the majority thought that the experience was ‘good’ or ‘excellent’. They particularly valued meeting and networking with other midwives and sharing concerns about practice issues.
It is clear that group supervision may be useful in health professions, including midwifery. This paper will now focus on five questions that may be raised about clinical and group supervision.
How much does clinical supervision cost?
The literature reviewed by Butterworth et al (2008) largely reports on group supervision taking place over a limited time frame (usually 3 months to 1 year). The papers also commonly refer to standardised processes for the frequency and length of the group meetings (commonly weekly, fortnightly or monthly and each lasting 1½–3 hours). There is no available evidence that relates to supervision on a less frequent basis.
However, in a cash-strapped NHS, it is essential to consider the potential costs of clinical supervision. This has been explored by Holmes et al (2010), who undertook their assessments into supervision in social services following the recommendations of the Laming (2009) review into the Baby Peter case. However, due to its complexity, it proved to be virtually impossible to reach a definitive conclusion as to the cost implications of clinical supervision.
An earlier Finnish study also explored a cost–benefit analysis of having a system of ‘team group supervision’ (Hyrkäs et al, 2001). Team supervision was undertaken on one ward and the researchers analysed statistical data including annual reports, sickness records and indemnity reports. They concluded that team supervision was efficient in economic terms and recommended further testing and refinement of their formula. This type of costing could be applied to UK NHS settings, but to date there does not seem to be any published evidence of this. However, Francis and Byford (2011) warn against such crude assessments as they do not take into account the benefits of supervision to workers or to people who use services; the authors note that such measurements should include the perspective of service users.
Costs are likely to be lower in group supervision than in one-to-one supervision, as noted by Milne and Oliver (2000: 301):
‘Whichever style one adopts, the advantages of a group format appear to extend beyond the current concern with numbers and efficiency.’
Should clinical supervision be part of management processes?
The role of the clinical supervisor was highlighted in a US study involving people from eight different health care disciplines. The researchers explored group supervision and asked what aspects were most important (Cutcliffe and Hyrkäs, 2006). The 74 nurses, chiropodists, occupational therapists, physiotherapists and health visitors ranked 17 statements in order of how much they agreed with them. Almost all respondents agreed that confidentiality is assured and agreed in the groups, but there was low agreement with the statement that supervisors should also be managers. The overall conclusion of the study was (Cutcliffe and Hyrkäs, 2006: 626):
‘The importance of having a clinical supervisory relationship that remains separate from administrative/managerial supervision and one where confidentiality is assured was highlighted by this study. Furthermore, the attitudes were not restricted to one professional or disciplinary group. The effective support system of clinical supervision should therefore not be diluted by awkward and unnecessary amalgamations with administrative/managerial supervision.’
Facilitation of group supervision is considered to be a complex skill; for example, Milne and Oliver's (2000) findings were not wholly supportive of group supervision as they highlighted the potential negative influence of rivalry between peers within groups; they concluded that considerable skill is required by supervisors when facilitating group supervision.
In one study, concerns were raised about the lack of preparedness of the supervisor, the low status of supervision and the associated lack of support from management for supervision activities (Malin, 2000). The specialised skills of the supervisor in group supervision were also explored in depth in a Swedish study (Bondas, 2010). Hermeneutic interpretation was undertaken with written narratives from 24 highly experienced nurses/clinical supervisors. The researcher was especially interested in concepts of leadership, both in terms of the participants' own work as a supervisor, and in terms of what was discussed in the groups. Findings from this study indicate that group supervisors valued continuity (in terms of them continuing in the role), excellent listening skills and integrating reflections with theories (of nursing), and they clearly viewed their role as distinct from management (Bondas, 2010).
Can group supervision improve evidence-based practice?
In a Norwegian longitudinal study over 2 years, 25 nurse participants reported an improvement in the integration of theory and practice, stating that attending supervision helped to confirm their knowledge and increased their self-awareness in practice (Landmark et al, 2004).
Group supervision was also used to increase evidence-based practice in nurses in Scotland. Researchers were interested in exploring improvements in evidence-based practice in three types of environment (Tolson et al, 2008). Twenty-four nurses from 18 practice sites formed three groups, and each group selected an aspect of evidence-based guidance to implement. A modified group supervision framework was implemented, with the aim of empowering the nurses to champion implementation of evidence into practice. Six months later, results showed success in implementing evidence into practice.
The researchers concluded that (Tolson et al, 2008: 682):
‘Implications for nursing management time and budgetary constraints necessitate smart, value for money approaches to developing evidence-based practice and improved care standards. This work demonstrates an effective model that strikes a balance between individual and group learning, virtual and real-time activities, coupled with resource pooling across organizations and sectors.’
Improved integration of theory and practice, as well as a positive impact on professional competence, was also found in an earlier study (Arvidsson et al, 2001). The 10 participants were mental health nurses early in their careers. They were interviewed about their experiences with group supervision on two occasions, after 1 year and 2 years, respectively. The researchers concluded that supervision enhanced the integration of practice and theory, resulting in enhanced nursing competence among the participants.
‘Group supervision has been found to be useful in maintaining professional resilience in high-pressure situations’
Can group supervision enhance professionalism?
Research has shown that group supervision can help in developing a sense of professional identity (Segesten, 1993). Segesten (1993) devised a paper-based questionnaire, which was completed by all registered nurses in two orthopaedic wards, before and after a 4-month period of professional group supervision, focusing on professional identity. The results demonstrated that professional identity was enhanced by the intervention.
It also had a lasting effect in another study; Arvidsson et al (2001) found six emergent themes in their study with 10 mental health nurses. These were: a feeling of job satisfaction; gaining knowledge and competence; gaining a sense of security in nursing situations; a feeling of personal development; realising the value of supervision; and a sense of professional solidarity.
In Scandinavia, group supervision is used with preceptors (the title used for mentors or practice teachers), resulting in a perceived improvement in professional thinking and personal and professional development (Danielsson et al, 2009; Borch et al, 2013). In another qualitative study, group supervision was used to particularly good effect with paramedics, enhancing participants' personal and professional development and to help newer colleagues to develop their expertise (Brink et al, 2012). The researchers concluded by stating (Brink et al, 2012: 76):
‘It is to be hoped that the results of this study will interest health managers and encourage them to consider group supervision as a tool for professional development not only within the area of the ambulance service.’
Can group supervision reduce workplace stress and sickness rates?
Group supervision has been found to be particularly useful in maintaining professional resilience in high-pressure situations (Wallbank, 2013), which is likely to be especially useful in pressurised health care contexts. In a recent study, researchers undertook a survey with 113 recent nursing graduates from three universities (Blomberg et al, 2016), aiming to investigate occupational stress among newly graduated nurses. Stress was high among the newly qualified nurses, with surgical nurses reporting the highest levels of stress. However, the researchers found that (Blomberg et al, 2016: 85):
‘Nurses who had received clinical group supervision reported significantly less stress… It is important to develop strategies that help to adapt the work situation so as to give nurses the necessary support. Clinical group supervision should be considered as an option for reducing stress.’
An earlier qualitative study reported similar findings (Ohlson and Arvidsson, 2005). A UK study involving clinical nurse leaders in an NHS hospital setting also found similar outcomes (Ashburner et al, 2004). In the UK study, 52 nursing leaders (F, G, H and I grades) working in one hospital took part in an action research project, attending group supervision and taking part in semi-structured interviews over a 4-year period. Data were also collected on staff turnover and sickness rates (Ashburner et al, 2004). The findings suggested that group supervision helped to build the leaders' confidence, supported them through crises and appeared to be linked with a significant reduction in sickness rates. It should be noted, however, that this study involved fortnightly group supervision of 1½ hours. The researchers also noted that not all participants were comfortable with the experiential nature of clinical supervision, and that attendance at the meetings was erratic. Despite this, the project persisted throughout the 4 years of the study period (Ashburner et al, 2004). The supportive aspect of group supervision was also highlighted in a study involving nurses in an intensive care unit setting. The groups met every third week and the researchers found that it improved their interpersonal skills and their sensitivity in nursing practice (Lindahl and Norberg, 2002).
Group supervision has also been shown to improve nurses' feelings about their work. In their descriptive-correlational study, Bégat et al (2005) recruited 71 nurses from two hospitals, some of whom had taken part in supervision and some who had not. They were asked to complete questionnaires related to nurses' satisfaction with their psychosocial work environment and their moral sensitivity. The results showed differences between nurses who were and were not attending group supervision, and between ‘physical symptoms and anxiety’ and ‘feelings of not being in control’. The researchers concluded that ethical conflicts in nursing are a source of job-related stress and anxiety, and that supporting nurses by clinical nursing supervision may have a positive influence on their perceptions of wellbeing, motivation, anxiety and being in control of their situation.
Finally, a team of GPs in a practice in Bristol were concerned about workplace stress and burnout. They set up a system of group supervision in their practice, led by a non-medical psychotherapist as their supervisor (Porteous and Atkins, 2014). Their report in the BMJ discusses how they set up and ran sessions lasting 1 hour every fortnight. At the time of writing the paper, the groups were fully attended and reportedly very successful in terms of improving the GPs' own feelings as well as developing their practice (Porteous and Atkins, 2014).
There is ample evidence to support the view that clinical supervision—and, in particular, group supervision—is thought to confer many benefits in health care settings. Group supervision should not be confused with management, but its benefits include improving how practitioners feel about their practice, improving evidence-based practice, enhancing professionalism and reducing workplace stress and sickness rates. With the impending withdrawal of statutory supervision of midwifery in the UK, this paper has explored the research related to clinical supervision and group supervision. Part 2 (to follow in a future issue) will present the findings from several sets of data exploring the value of group supervision in midwifery in Wales.