Clinical supervision as a model for clinical leadership

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<ul><li><p>Clinical supervision as a model for clinical leadership</p><p>CHRISTOPHER JOHNS P h D , R N</p><p>Reader in Advanced Nursing Practice, University of Luton, Bedfordshire, UK</p><p>Introduction</p><p>Clinical leadership is acknowledged as a cornerstone for</p><p>the development for nursing and health care practice in</p><p>successive Government strategy documents Vision for</p><p>the Future (NHS Management Executive [NHSME]</p><p>1993) and Making a Difference (Department of Health</p><p>[DoH] 1999). These strategy documents set a back-</p><p>ground for a new NHS that has a strong vision and</p><p>commitment, is responsive to innovation and change,</p><p>with a strong nursing leadership. Alongside this Gov-</p><p>ernment agenda is a contemporary literature that sug-</p><p>gests the nature of nursing leadership needs to change in</p><p>order for nursing to make a meaningful contribution</p><p>within organizations and assert a nursing agenda</p><p>(Vladeck 1992, Schuster 1994). Or put another way, a</p><p>leadership that is adequately prepared to respond posi-</p><p>tively and effectively to both Government and profes-</p><p>sional agendas. As Sofarelli and Brown (1998) note in</p><p>reviewing the transformational leadership literature:</p><p>A transformational leader will provide the skillsfor the profession to stretch its boundaries and be</p><p>innovative in the way in which problems are</p><p>viewed and solved and will move nursing</p><p>further into the centre of the arena of health care</p><p>services. (p. 203)Transformation is to change the nature of something.</p><p>Authors such as Barker and Young (1994) and Klakovich</p><p>(1994) view the transformational leader as someone to</p><p>lead or liberate nursing from the dark shadows of patri-</p><p>archy and oppression so nursing can assert and fulfil its</p><p>own agenda in collaborative ways within the organiza-</p><p>tion. This position suggests that nursing leadership has</p><p>failed to achieve this, both being viewed and viewing itself</p><p>as a subordinate and powerless workforce whose agenda</p><p>is set and controlled by more powerful others. While the</p><p>idea of transformational leadership is espoused as an ideal</p><p>within the nursing literature, it does not mean it is desir-</p><p>able within health care organizations despite the Gov-</p><p>ernment rhetoric. Indeed, transformation of nursing must</p><p>inevitably mean transformation of the organization itself</p><p>as it accommodates new patterns of relationships. Indeed,</p><p>it is likely that the organization, whilst paying lip service to</p><p>transformational leadership, will covertly resist it because</p><p>of the inherent threat to established patterns of relating.</p><p>Besides targeting clinical leadership, the Vision for theFuture document (NHSME 1993) also targeted thedevelopment of clinical supervision as a means to enable</p><p>Correspondence</p><p>Christopher Johns</p><p>4 High Street</p><p>Riseley</p><p>Bedfordshire MK44 1 DU</p><p>UK</p><p>E-mail: chris.johns@luton.ac.uk</p><p>J O H N S C. (2003) Journal of Nursing Management 11, 2534Clinical supervision as a model for clinical leadership</p><p>Clinical leadership and clinical supervision are topical areas of nursing develop-</p><p>ment. A project was established to facilitate the growth of leadership ability with a</p><p>group of ward sisters through individual clinical supervision. The work revealedthat ward mangers struggled to fulfil their leadership roles largely because of</p><p>embodied ways of relating within a prevailing organizational culture that</p><p>constrained them. The paper also reflects on the impact of supervision todevelop leadership practice.</p><p>Keywords: clinical supervision, leadership, organization, transformation, ward managers</p><p>Accepted for publication: 18 April 2002</p><p>Journal of Nursing Management, 2003, 11, 2534</p><p> 2003 Blackwell Publishing Ltd 25</p></li><li><p>practitioners to accept responsibility for developing and</p><p>sustaining effective practice and safeguarding patient</p><p>care. As such clinical supervision might be viewed as a</p><p>developmental process to enable the growth of clinical</p><p>leadership at ward manager level. As Making a Differ-</p><p>ence (DoH 1999) notes ward managers have a pivotalrole in NHS Organizations (p. 53), and were therefore akey focus for developing leadership.</p><p>The contemporary leadership literature espouses a</p><p>transformational leadership style required to respond to a</p><p>postindustrial paradigm (Rost 1994). Examples of this new</p><p>transformational style are found in business (Schuster</p><p>1994), in health care (Trofino 1995), nursing (Sofarelli &amp;</p><p>Brow 1998, Dunham &amp; Klafehn 1990). Trofino (1995)</p><p>makes the distinction between a transactional and trans-</p><p>formational leadership style. The transactional style is</p><p>functional towards achieving a specific outcome based on</p><p>an exchange system that the follower values. The transfor-</p><p>mational style is based on relationship where people work</p><p>together towards realizing shared vision and shared success,</p><p>both personal and organizational. Such a leadership style is</p><p>motivating and energizing for both leaders and followers.</p><p>The transactional leadership style tends to be characterized</p><p>by an emphasis on positional, reward and sanction types of</p><p>power, whereas the transformational leadership style is</p><p>characterized more by relational and expert types of power</p><p>(French &amp; Raven 1968). The consequence is a fundamental</p><p>shift of the way power is used within organizations.</p><p>Transformational leadership views all experience as</p><p>opportunity for learning. As such the organization</p><p>becomes reflective, establishing what Senge (1990) calls</p><p>the learning organization; an organization that is more</p><p>holistic, flexible, responsive, proactive, and caring. In</p><p>other words, it is an organization that lives its values and</p><p>works hard to identify and resolve contradictions</p><p>between its values and its practice. Reflection is the core</p><p>of clinical supervision (Bond &amp; Holland 1998, Rolfe</p><p>et al. 2001), suggesting that clinical supervision may</p><p>provide a congruent learning opportunity to develop</p><p>transformational leaders within nursing.</p><p>Research aim</p><p>In response I established a study to implement and evaluate</p><p>the impact of clinical supervision in facilitating the growth</p><p>of the clinical leaders leadership ability within the medical</p><p>and elderly care directorate of a large general hospital.</p><p>Sample</p><p>Initially [what I described as Phase 1] I contracted with</p><p>nine ward managers to enter into individual clinical</p><p>supervision with the explicit aim of facilitating their</p><p>clinical leadership role (3 H grade; 5 G grade; 1 Fgrade). The ward managers, or who I shall refer to as</p><p>leaders, accepted my invitation to participate in theproject following a project presentation. Six months</p><p>later, an H grade ward manager from the surgical</p><p>directorate was recruited for the project on the condition</p><p>that she simultaneously supervised two G grade wardmanagers in the surgical directorate, again with the</p><p>explicit aim of facilitating their clinical leadership role</p><p>(Phase 2). She also contracted with a D grade staff nurseon her own ward. None of the contracted leaders had</p><p>previously experienced clinical supervision. All the ward</p><p>managers were female.</p><p>Method</p><p>In both phases of the project, we agreed to meet for</p><p>clinical supervision for 1 hour every 21 days. This would</p><p>total 15 sessions over a 12-month period. However, in</p><p>Phase 1, the exigencies of everyday practice determined a</p><p>different schedule that could not have been predicted.</p><p>The practitioners agreed to bring everyday experiences to</p><p>reflect on that they felt were significant in fulfilling their</p><p>leadership role. Reflection enables practitioners to sur-</p><p>face, confront, and work towards resolving contradic-</p><p>tions between the way he/she practised and what is</p><p>desirable in terms of effective leadership (Johns 1998).</p><p>Kieffer (1984) highlights the significance of revealing</p><p>contradiction as a catalyst for empowering self towards</p><p>realizing selfs best interests and the crucial role of an</p><p>external enabler to support and challenge the person</p><p>through the developmental process. As the clinical</p><p>supervisor, I was conscious not to impose my own</p><p>interpretations on their experiences. Clearly, it was</p><p>important to establish the conditions of trust so the</p><p>practitioners felt safe to disclose their experiences. Just</p><p>because collaboration is espoused, does not mean we were</p><p>able to participate on equal terms in practice. Collabora-</p><p>tion had to be actively constructed within the relationship</p><p>as an explicit aspect of the learning process (Webb 1990).</p><p>This was, in itself, a significant aspect of learning, because</p><p>we assumed that the effective clinical leader is someone</p><p>with a strong sense of self, who accepts responsibility for</p><p>self, is assertive and able to establish collaborative rela-</p><p>tionships as far as possible with other health care workers.</p><p>Evaluative approach</p><p>To evaluate the development of leadership, I developed</p><p>the clinical leadership template. The template adopts a</p><p>functional approach to defining the clinical leadership</p><p>C. Johns</p><p>26 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 2534</p></li><li><p>role. It consists of eight core leadership roles that were</p><p>agreed with clinical leader as representative of their</p><p>leadership role. Discussing and agreeing the template</p><p>was helpful for the clinical leaders to become aware of</p><p>their leadership roles and the extent they currently</p><p>fulfilled it. The template (Figure 1) was itself tested and</p><p>transformed within the research process to more ade-</p><p>quately represent the leadership role.</p><p>During each session I recorded the dialogue</p><p>between myself and each practitioner. These notes</p><p>were word-processed within 24 hours and given to</p><p>each practitioner for their agreement. These were</p><p>generally acknowledged as accurate. As one H grade</p><p>(Delia) commented The notes were absolutely right,very accurate. Each subsequent session commencedby picking the issues from the previous session. Did</p><p>the leader take action as anticipated? What happened</p><p>as a consequence? What factors constrained action?</p><p>The notes built session by session as an unfolding</p><p>reflexive narrative to reveal its subtlety and uniqueness,</p><p>and those factors that had constrained the practitioner in</p><p>realizing effective clinical leadership. Interspersed between</p><p>the dialogue, I wrote interpretative summaries that plotted</p><p>the growth of leadership. The narrative approach</p><p>respected and highlighted the way each leader responded</p><p>to the opportunity to develop their leadership role through</p><p>clinical supervision. Each practitioner was given a pseud-</p><p>onym which are used within this paper (Table 1).</p><p>A meta-analysis of the narratives revealed and dis-</p><p>cussed the factors that seemed to constrain the realiza-</p><p>tion of leadership potential within each aspect of the</p><p>clinical leadership role (Figure 1). These issues are dis-</p><p>cussed.</p><p>Findings</p><p>The majority of experiences the clinical leaders shared</p><p>were characterized by anxiety and conflict, and with</p><p>negative feelings such as anger, frustration, guilt and</p><p>despair. Few experiences indicated their satisfaction with</p><p>work. I was conscious that the overwhelming negative</p><p>focus of experiences may skew the narratives as repre-</p><p>senting lives as generally problematic, yet in terms of</p><p>realizing clinical leadership this did seem true.</p><p>Developing a vision for practice</p><p>Managing vision is central to transformational leadership</p><p>(Senge 1990, Sofarelli &amp; Brown 1998). Vision gives</p><p>meaning and direction to practice and unites staff in</p><p>common purpose. Without exception, the practitioners</p><p>lacked a clear vision for practice despite written wardphilosophies. However, these emerged as little more thatthan vague statements that had little practical meaning. As</p><p>reflected in the way the leaders talked about their work,</p><p>they tended to define work and themselves from a func-</p><p>tional perspective. When challenged they struggled to</p><p>conceptualize practice in terms of values. For example,</p><p>when Tessa became a G grade I challenged her to reflect on</p><p>ward values at her first team meeting. However, she felt it</p><p>was more important to focus on the little things, such aspatients having a glass of water at hand; typifying theprevailing functional perspective. Given the centrality of</p><p>vision to leadership role, only two practitioners</p><p>reconstructed their philosophies for practice in meaning-</p><p>ful ways to focus nursing practice and development. In</p><p>defence, the practitioners justified their passivity to create</p><p>meaningful vision in terms of being locked into a medical</p><p>model that defined caring and felt unable or were reluc-</p><p>tant to assert a nursing identity.</p><p>Maintains expert clinical credibility</p><p>Perhaps one reason that the practitioners did not easily</p><p>engage the idea of vision was that they felt they had become</p><p>increasingly remote from everyday clinical practice</p><p>reflected in the fact that few of shared experiences were</p><p>grounded in clinical experiences with patients and families.</p><p>One consequence was that they were not so available to</p><p>lead by example. Their lives revolved around managerial</p><p>issues. It was an area of considerable frustration because</p><p>they all wanted to be more involved in direct patient care.</p><p>Two of the H grades viewed their future in management</p><p>Develops and maintains avalid vision for practice</p><p>Maintains expert clinical credibility Ensures the overall quality of care</p><p>Manages self to maintain charismaand effectiveness</p><p>Clinical leadership role</p><p>Facilitates staff to fulfil role responsibility</p><p>Facilitates the development of clinical practice</p><p>Facilitates the development and support of staff competence</p><p>Manages the unit effectively- systems for delivery of care- selection for personnel- resource management- meeting and influencing organizational objectives- ensuring effective communication- establishing collaborative multi-discliplinary working relationships</p><p>Figure 1Clinical leadership template</p><p>Clinical supervision</p><p> 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 2534 27</p></li><li><p>and felt less dissonance in their role than some of the other</p><p>leaders who were struggling with their loss of caring role.Beattie, one of these two H grades, perceived her staff felt</p><p>that she had no clinical role at all which led to conflict with</p><p>her senior ward staff about who actually managed clinical</p><p>practice. The lack of visible clinical role undermined the</p><p>leaders expert and relational sources of power (French &amp;</p><p>Raven 1968). As a consequence, more authoritative sour-</p><p>ces of power, such as positional power, were emphasized</p><p>that constrained the development of collaborative</p><p>relationships viewed as central to transformational lea-</p><p>dership (Sofarelli &amp; Brown 1998). Some leaders, notably</p><p>the H grades, successfully devised strategies to increase the</p><p>percentage of their time devoted to clinical practice, lead-</p><p>ing to a marked improvement in personal satisfaction and</p><p>perception of self as leader (rather than manager). In other</p><p>words, they perceived that clinical leaders have strong</p><p>clinical roles.</p><p>The experiences of clinical practice that were shared</p><p>were profound and led to very significant personal and</p><p>practice development. For example, Shirley disclosed:</p><p>A daughter of a woman who had had a biopsy ofpancreas as a day case stopped me in the corridor.</p><p>She said I dont want my mother told about herdiagnosis. She was really quite d...</p></li></ul>

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