clinical supervision using video-conferencing technology: a reflective account

Clinical supervision using video-conferencing technology:a reflective account

CAROL E. MARROW M P h i l , B A ( H o n s ) , C e r t . E d , R M N , R G N , P h D1, KIM HOLLYOAKE B A ( H o n s ) , D P S N , R G N

2,DOROTHY HAMER M A , D N , R G N

3 and CATHERINE KENRICK B S c , R G N4

1Senior Lecturer, St Martin’s College, Lancaster; 2ENB 124 Sister, Coronary Care, WGH, Kendal; 3RNM DistrictNursing Sister, Bay Community Trust, Lancaster and 4Senior Staff Nurse, Intensive Care, Furness General Hospital,Barrow-in-Furness

Introduction and background

One of the major initiatives in the Government’s recent

proposals to �modernize� the National Health Service

(NHS) is Clinical Governance. Clinical governance is a

quality framework that helps clinicians to continuously

improve and maintain standards of care. Included

within this framework are areas such as clinical audit,

risk management, evidence based practice, patient

input and feedback, clinical supervision, continuing

Correspondence

Carol E. Marrow

The Barn

Eden Mount

Grange Over Sands

Cumbria LA11 6BZ

E-mail: [email protected]

M A R R O W C. E., H O L L Y O A K E K., H A M E R D. & K E N R I C K C. (2002) Journal of NursingManagement 10, 275–282Clinical supervision using video-conferencing technology: a reflective account

This paper discusses three nursing practitioners’ experiences of clinical supervisionusing video-conferencing (VC) technology.

The study, based on supportive action research, involved 40 practising community

and hospital nurses from a variety of specialities and took place over an 18-month

period. The research was collaborative, educational and applied and focused on the

effects of remote clinical supervision on the development of professional practice.

Data were obtained through pre- and post-study questionnaires, repertory grids,

focus group interviews and written narratives.

The three research participants found that clinical supervision, as a mediator of

learning, was vital in enabling them to develop their reflective and problem-solving

skills. Through critical conversations with either a supervisor or within peer group

supervision, the participants increased both their confidence and self-awareness and

gained more insight into the practices and needs of other practitioners. They also

examined critically patient care issues resulting in attention to existing or the de-

velopment of new care protocols. They did, however, experience some impediments

to the process of clinical supervision, mainly lack of peer and management support

and ongoing education.

The participants had mixed perceptions with regards to using VC technology for

clinical supervision. They experienced technical and accessibility problems and

communication problems, suggesting the need for clear protocols for both technical

support and applied training.

Keywords: clinical supervision, reflexivity, supportive action research, video conferen-

cing technology

Accepted for publication: 1 October 2001

Journal of Nursing Management, 2002, 10, 275–282

ª 2002 Blackwell Science Ltd 275

professional development and reflective practice (RCN

1998).

Further, the importance of support for health care

practitioners is paramount in the current NHS climate

(Hingley & Harris 1986, Pesut & Williams 1990,

Lowry 1998) and even more particularly with the recent

merger of NHS Trusts. The centralizing of administra-

tive functions has to some extent left many practitioners

feeling isolated, particularly those working in rural and

semi-rural communities. Added to this, the emphasis on

practitioner accountability and responsibility for care

decisions and the drive for evidence-based practice,

further demonstrates the need for the development of a

reflective practitioner and a professional relationship

(such as clinical supervision), which enables construct-

ive dialogue to take place (Johns & Freshwater 1998,

Johns 2000).

A study developed from the findings of a north-west

regional pilot (Marrow & Yaseen 1998), examined and

evaluated the process and outcomes of clinical super-

vision using video-conference (VC). This paper will

focus on the reflexive accounts of three of the study

participants. However, for clarity a resume of the study

background and design is outlined.

The image of clinical supervision

In nursing there are a variety of meanings and intentions

of the term �clinical supervision� and these focus on an

assortment of areas. Barber and Norman (1987) iden-

tified clinical supervision as facilitating professional

development and having four key functions, education,

support, management and self-awareness. Jones (1998)

investigated the impact of clinical supervision on the

work of Macmillan nurses and found that clinical su-

pervision could help uncover tacit knowledge and

therefore could be considered as an important devel-

opment tool. Severinsson and Borgenhammer (1997)

also suggested that clinical supervision was about edu-

cation and achieving full potential. Other authors,

through research and experience, recognize that clinical

supervision is ultimately about support and patient care

(Kaberry 1992, Wright 1993, Faugier & Butterworth

1994, Darley 1995, Olsson et al. 1998, Lees 1999).

Research design

The study was awarded funding from the NHS Execu-

tive north-west and the North Lancashire and South

Cumbria Education and Training Consortium, and

commenced in the autumn of 1997 and concluded in the

summer 1999.

Two general research aims were identified and these

were comparable with the literatures general image of

clinical supervision. The first aim was to provide a

supportive and sharing relationship across a wide geo-

graphical area (clinical supervision using VC) that

empowered the supervisors and supervisees to reflect on

their own competencies. This would then help to faci-

litate the development of professional knowledge and

skills, thus enhancing standards of care.

The second aim was to evaluate the impact of clinical

supervision on the participants’ beliefs and practices

whilst engaged in communities of practice.

The first aim was met through the use of collaborative

action research based on the work of Heron (1996) to

support the professional development of participants as

they worked with clinical supervision and incorporated

it into their practices. We therefore named this type of

action research as supportive interactive research.

The second aim called for initial, midpoint and end of

study assessments of beliefs and practices of practi-

tioners and these were identified using questionnaires

and repertory grids. Ongoing group conversations (fo-

cus groups) also helped to meet both the research aims

and in particular identify clinical and patient care ini-

tiatives.

The theoretical frameworks used to analyse supervi-

sory and clinical practice issues were Six Category

Intervention Analysis (Heron 1990); Critical Incident

Analysis Johns 1994, 2000) and Developmental Levels

Analysis based on the work of Stoltenberg and

Delworth (1987).

The research participants

The research sample consisted of 40 practising nurses

from a variety of specialities both in acute and com-

munity care. These participants took part in four

preparatory days for the implementation of clinical

supervision and a further 2 days focusing on the

effective use of the VC technology.

Examination of the principles of clinical supervision,

means of acquiring data, development of theoretical

frameworks and ground rules for the study, including

ethical considerations were discussed and agreed at the

workshops.

The findings from this study were extensive, and to

offer the reader a flavour of the work three nurses have

offered to share their experiences as practitioners

engaged in remote clinical supervision. These shared

experiences are personal to the individual participant,

and although many of the issues they identified are

pertinent to the wider sample group, these are their own

C. E. Marrow et al.

276 ª 2002 Blackwell Science Ltd, Journal of Nursing Management, 10, 275–282

interpretations of the events and processes they

experienced whilst engaged in supportive interactive

research. They are, however, considered valuable in

informing professionals who are considering imple-

menting clinical supervision with or without the VC

technology.

Many of the participants in the project experienced a

positive process of clinical supervision. However, there

were some that were exposed to a number of problems

and these have been outlined in their personal reflec-

tions.

Reflexive accounts

Case study one

Pen portrait

This participant was a District Nursing Sister/Midwife

working in a rural community who participated in

remote peer group clinical supervision with three other

district nurses.

Reflections

In March 1982, I commenced practising in this dual

role as single-handed practitioner. Following the NHS

reforms of the eighties and nineties, I experienced sev-

eral organizational changes resulting in the implemen-

tation of Government Reports [HMSO (1988)

Community Care: Agenda for Action 1988; Working

for Patients and Caring for People (HMSO 1989)].

Changes were experienced by most staff within the

Trust, particularly changes in the community managers’

style and approach. In their guide to effective imple-

mentation of change management, many factors such as

the nature and definition of change, including the sup-

port and guidance throughout a period of transition,

impinge on the successful management of change within

an organization (McCulman & Paton 1992).

Regrettably, this support and guidance was not appre-

ciated at that time. The changes were traumatic for

others and me and were later identified as bullying

(Coombes 1996, 1997, Meehan 1997).

I was desperate for support and remained fearful of

my managers. Aware of my feelings I learned to �self

manage�, immersing myself into my work, keeping up to

date and concentrating on further self-development.

In May 1998 more changes occurred. This time I

was requested to lead a team of community nurses,

albeit a small team. This was different from working

alone and therefore this leadership role concerned me.

During Spring 1998 letters were disseminated to the

local NHS Trusts inviting interested parties to parti-

cipate in a clinical supervision research project. I

considered that this might be helpful in solving my

problems.

In June 1998, following the introductory training

days of the research projects, three colleagues and I

commenced the first clinical supervision session. The

venue for the session was the home of one of the par-

ticipants and Heron’s Six Category Interaction Analysis

(1990) model was utilized. This model aimed to help us

analyse our supervisory skills in order to promote

growth and development of the supervisory role and

thus, a successful experience of clinical supervision.

The session was well structured as ground rules and

confidentiality were addressed at the outset and inclu-

ded:

• All matters to be professionally related.

• Content of the discussions to remain in the group.

• The sessions to last for 1 hour.

The agenda took the form of a clinical supervision-

planning sheet that helped us to focus on (a) issues from

the previous session; (b) subsequent issues and (c)

agreed objectives. No one person took the lead; the

session was equal, open and amicable. It was very

supportive and I expressed this in the focus groups:

�I�ve found it really supportive because I have been

so isolated and I’m sure … feels the same way

because we are the only two at this end… It is very

rare that we get to be together. Therefore, to link

with another two people who are doing the same

job, it is really supportive. It’s been good’.

�I remember saying before we got into groups Oh

roll on clinical supervision. I felt desperately in

need of that…the fact that I have had to change

and the concerns that I had from being a single-

handed practitioner to having staff members. I feel

that the group helps me.�We discussed many issues relating to clinical practice.

One of the topics we discussed was related to the

standards of care in residential and nursing homes. This

discussion triggered my thoughts relating to a particular

residential home with which I was professionally

involved. There had been some problems identified and

through the clinical supervision sessions I was able to

explore the issues safely and receive constructive feed-

back regarding my decisions and actions. The issue was

also brought to the fore in our focus group meeting and

the following transcript of evidence illustrates the

strength of my feelings:

�I was concerned about two patients (regarding

safety) whom I thought should have been in a

nursing home rather than a residential home and I

Video conferencing technology: a reflective account

ª 2002 Blackwell Science Ltd, Journal of Nursing Management, 10, 275–282 277

mentioned this to the owner of the home. I felt

that they should have had two staff on at night

and of course, he did not argue with it, but he

obviously wasn�t happy because that’s money you

see. We did find a resolution to this regarding

handling the patients more safely with fewer

staff.’

This issue has now been resolved satisfactorily

through ongoing discussions in clinical supervision.

To help the participants reflect on professional issues

we were encouraged to keep a reflective diary.

According to Heath (1997) diaries are useful in helping

to facilitate development in practice through the re-

flective process. Keeping a reflective diary has aided my

ability to understand and appreciate how I felt at the

time of practising, thereby enhancing my cognitive skills

and consequently improving my future professional

performance when delivering care.

Reflective practice has facilitated my aptitude to

analyse my actions and further develop my skills,

knowledge and experience. Whether that reflection is a

positive or negative experience still remains for me an

important part of the learning process. Effective clinical

supervision enhances the development of these reflective

skills through constructive dialogue and is thus, per-

ceived as a vital component of nursing that aids the

pursuance of excellence within practice. Hall (1996)

elaborates on how clinical supervision can be perceived

as a �tool� that gives support and feedback in the case of

District Nurses working as self-determining practition-

ers in the community setting. Clinical supervision has

given me more confidence, increased my self-awareness

and has facilitated my awareness of other needs and

welfare of the staff resulting in an improvement of

patient care in the community.

Case study two

Pen portrait

This participant, who took part in remote peer group

clinical supervision with three other coronary care

nurses, is a sister in charge of a four-bedded coronary

care unit in a semi-rural area.

Reflections

Our nursing team have been considering clinical

supervision for some time, although, like Reid (1993),

we believed that we would only be putting an official

title to something already done.

I was interested to see which areas we needed to

address and also wondered whether we were deluding

ourselves into thinking that the almost daily discussions

we have about patient care, ward management or staff

development could be classed as supervision or was it

simply incidental reflection (Darbyshire 1993). Our

initial group of four had included a junior team member

who wanted and may have benefited from development,

unfortunately this fourth member left the Trust just

prior to the project beginning, we therefore became a

group of three very experienced nurses without the

focus we had anticipated.

In order to feel comfortable in disclosing information,

our first session was a face-to-face meeting. We dis-

cussed what we wanted to focus on and what we hoped

to gain from clinical supervision, we also established

our ground rules. At the end of the first session we

decided that each of us would bring one positive and

one negative experience to the next session and reflect

on them. Butterworth and Faugier (1992) view clinical

supervision as a means of protection for nurses by

reducing isolation in stressful situations. Reflecting on

the scenarios proved to be very therapeutic as we were

able to help, guide and support each other. Houston

(1990) identifies various limitations of peer group

supervision highlighting the potential for them to be

moaning sessions devoted to topics out of the control of

the group. We did not experience this phenomenon as

we remained focused on topics that were relevant to our

practice.

Occasionally, because of us not being able to get

together to either use the VC facilities or to meet up

face-to-face, we lost some momentum. Hence, our

experience was probably marred by this discontinuity.

Our biggest single problem was working in shifts; with

personal commitments, sickness and annual leave all

contributing to the creation of long gaps between some

of the sessions. Those practitioners working regular

hours might find meetings more attainable than a group

working in a variety of shifts.

We re-focused our sessions by looking at our indi-

vidual units; we swapped information, protocols and

documentation. This benefited us greatly, as some

people had felt that a smaller unit would deliver an

inferior service, we soon realized that we were speaking

the same language, doing the same things and experi-

encing the same problems. We now view each other’s

units with respect and as a potential source of support.

As a group we have written the suggestions to our

cardiologist on how current protocols might be amen-

ded, these are now under review and so I feel positive

about our ability to influence change.

Training for use of the VC facility was, I feel, inad-

equate; it would have been useful to have had several

opportunities to practice prior to using it properly. Our

C. E. Marrow et al.


group was trained remotely during a VC, and whilst I

can now appreciate the strengths of this training

method, it depended upon my ability to access the

system; my fellow trainee admitted this would have

been impossible for her to do it alone. However, once

connected there were clear instructions from trainers on

the other end of the link (18 miles away) so the hands-

on approach to training did not present too many

problems and was more convenient than the journey.

There were some technical problems with the VC

facility, mainly associated with broken sound or no

picture. The problems resulted in some anxious and

distracting experiences for example:

�Initially very poor sound quality but improved

when extra microphone installed.��Seating did nothing to enhance a relaxed atmo-

sphere. The inevitable delay in sound transmission

did not help discussions. Non-verbal communi-

cation was greatly reduced.�We did, however, participate in some trouble-free

sessions, and it was far easier to go to the VC room than

drive a 36-mile round trip.

Other problems included 1 day per week access to the

room. This was further restricted by others using it, as

well as our duty commitments. A more flexible time-

table for using the room and equipment would have

increased our chances of getting together. In order for

our recipient to see our faces on screen we had to look

at a remote camera. I kept looking at the screen, at the

face of the other participant; she therefore would have

been looking at the side of my head! We tried sitting

further away from the screen and although eye contact

was better, volume was severely compromised; I do not

think we ever fully resolved this. A camera incorporated

into the screen with a good quality picture would have

been useful. There was also a time delay in the system

making the conversation stilted for example:

�Found VC detracted from communication, ima-

ges/movement were exaggerated and sound was

poor. Time delay in conversations was inhibitive

and didn�t enhance supervision.’

I now feel this encouraged us to listen more intently

than normal and wait for the other party to stop before

starting a response; perhaps we are all guilty at times of

interrupting.

On reflection, VC as a communication tool has much

potential, particularly for linking with distant col-

leagues. Initially, I felt VC was an invasive vehicle for a

confidential discussion. As a result of problems with

access and technical difficulties, we sometimes com-

muted between hospitals in addition to using the

equipment. Overall, I now feel that although we had to

overcome a few problems, the experience is far superior

to using the telephone or electronic mail as human

presence on screen enhances communication. I can

imagine there are those who would prefer to remain

anonymous in certain circumstances.

Clinical supervision has strengthened a link within

our Trust and can only enhance patient care and prac-

titioner welfare through the supportive relationship it

offers. I also feel that nurses are unlikely to develop new

skills if they are never challenged about current prac-

tice, thus clinical supervision facilitates autonomy

through constructive criticism and feedback. The

experience has enabled me to ask questions about my

own practice. It has made me re-focus on my role and

has made me ask myself how I can be a better nurse if I

am to remain in the clinical arena.

Case study three

Pen portrait

This participant was a senior staff nurse working in a

five-bedded general Intensive Care Unit (ICU) partici-

pating as a supervisee in one-to-one remote clinical

supervision.

Reflections

My interest in clinical supervision has grown over the

years and the opportunity to become part of a research

project involving clinical supervision seemed a natural

progression. Having no hands-on experience of clinical

supervision I decided to volunteer as a supervisee, with

the hope of not only playing a part within a research

project but also to help to improve my confidence, self-

awareness and knowledge.

The preparation workshops were invaluable. They

gave a solid basis for the project while introducing the

concept of clinical supervision. The training to use the

VC was not too intimidating but going live via the VC

medium for the first time was an experience not to be

forgotten! Being computer literate helped and the 1-day

training was sufficient. I viewed the VC technology to

be exciting and hoped it to be the way forward for

clinical supervision.

The research facilitator allocated my supervisor; this

allocation was imperative to the research project as

specialist practitioners needed to link together. My

supervisor was an intensive care nursing sister working

in a different hospital (46 miles geographical distance)

within the Morecambe Bay Hospitals NHS Trust. We

both decided that for the first few sessions we would

meet face to face. Thus enabling us to get to know each

other and build a trusting relationship. We were to



undertake one to one supervision, which is viewed as

more effective than group supervision because it enables

personal feelings to be discussed more freely and less

scope for intimidation (McCallion & Baxter 1995,

Skoberne 1996).

During the first meeting, ground rules for our sub-

sequent clinical supervision were established. My

supervisor was already experienced within the field of

clinical supervision, having helped implement it in her

own unit. She was very clear on how she wanted the

sessions to go, and we were able to establish some

negotiated ground rules and a contract was drawn up.

It was decided to base the sessions on the contents of

the reflective diary that I started at the beginning of the

project. Completing a diary proved a challenge to me.

Having never mentioned a diary before, I had to be very

disciplined to make entries on a regular basis. The diary

contained incidents, good and bad that had happened

during my working day. They were written in a

reflective manner. Reflection is increasingly becoming

recognized as �an essential component of professional

practice� (Hull & Redfern 1996, p. 88).

Each entry followed a set of key questions. All the

sessions took the form of me describing an incident

followed by an in-depth two-way discussions about the

incident: looking at issues such as how the incident

could have been handled in a different way and what I

had learnt from the experience. The discussions were

guided by Johns’ model of structured reflection (Johns

1998). Nursing as a practice based profession, needs

continually to review what occurs in practice and so

learn from that practice. If it is to develop, reflective

practice using a structured model offers an effective way

to do this (Elcock 1997).

This method enabled me to systematically confront

and clarify my thoughts and feelings on the issues.

This method worked extremely well because of my

supervisors’ knowledge and expertise. This is in

keeping with beliefs of Skoberne (1996, p. 292), �the

ideal supervisor is a person who possesses the neces-

sary professional knowledge and skills to fulfil the

role of enabling and supporting the supervisee to

grow into an effective practitioner in ways that are

unique and meaningful. The supervisor must also

create a restful, relaxed and trustful atmosphere.�Following these early sessions I was left feeling very

motivated towards my practice. This is keeping with

the work of Marrow, Macauley and Crumbie (1997,

p. 81), �… gained a clarity of thought… helped me to

develop a vision for my own learning needs in clinical

practice… resolve potential areas of conflict within

the practice’.

The focus of the sessions and the reflective aspects

helped immensely with the General Intensive Care

course (ENB 100) that I was studying for during the

project. Switching to using the VC seemed to suppress

the process; although technical problems with the VC

were minimal my motivation seemed to be effected.

Difficulties occurred with maintaining eye contact with

my supervisor. It was all too easy to look at the com-

puter screen instead of the camera. A very strange

feeling was created; talking to a computer in a room on

your own was not the simplest thing to do. This is

perhaps where group VC supervision sessions would

have been advantageous, i.e. more than one person in

the room at each site. Above all the VC technology

eliminated the personal touch.

The supervisor/supervisee relationship began to break

down. I am not sure whether it was purely the effect of

the VC or if other factors contributed, e.g. a Trust

merger was taking place at the time and our clinical

work areas were both going through a particularly busy

period. Thus, the sessions were being held in our own

time, commitment to the project was affected and there

were difficulties in organizing the sessions.

Although my first attempt at clinical supervision using

VC was not as successful as I had hoped, my faith in the

process has not been deterred. I still strongly believe

there is a place for clinical supervision and it holds the

key to the development of competent, confident, know-

ledgeable practitioners. Given the opportunity, I would

take part in the project again. I would recommend

anyone to get involved with clinical supervision and if it

is initially unsuccessful, then perseverance is essential.

With the help of my colleagues, plus the experience I

have gained by participating in this project, I intend to

implement clinical supervision into my work area.

Conclusion and beyond

It appears from the issues outlined in this paper that

effective clinical supervision can be an empowering

experience. It has, through a structured approach,

enabled the participants in this study to reflect on what

they have seen, develop conscious awareness of what

has taken place and seen more clearly issues related to

practice.

More specifically, the three participants have valued

the supportive function of structured clinical supervi-

sion. It has enabled them to develop working relation-

ships through improved communication. It has also

increased their self-awareness and reflective skills and

enhanced their understanding about practice resulting

in improvements in patient care protocols.

C. E. Marrow et al.


The use of the VC technology as a medium for clinical

supervision was also perceived as being of immense

value. It helped to reduce the stress and times involved

in travelling and promote an active communication

between practitioners working in similar specialities but

in distant workplace settings.

The three participants, however, did experience some

problems with both the process of clinical supervision

and the technology.

Whilst implementing and participating in clinical

supervision they felt that there was both a lack of

continuing education and support from colleagues and

managers.

The use of the technology also raised a number of

issues, in particular, the difficulties experienced in

accessing the equipment and the lack of ongoing

support and training.

On summarizing the data and through continuous

dialogue with the practitioners involved, the process of

clinical supervision and the idea of linking across a wide

geographical area has been a positive one. Some of the

participants have carried on the initiative by either

continuing to use the VC technology for clinical

supervision or implementing the strategy without the

technology in their own workplace setting.

In the current climate of staff shortages and immense

change, health care practitioners need a form of medi-

ation to help them develop their professional practice.

This study has highlighted the importance of an active

professional relationship that helps to motivate and

empower professionals in practice to ensure that good

standards of care are maintained and developed.

Future considerations

Employers should recognize and invest in the value of

clinical supervision whether using VC technology or not.

Employers should recognize the importance of quality

time for clinical supervision.

The training and education of supervisors and

supervisees should be a major investment. As well as

initial workshops there should be ongoing opportunities

for discussion of issues/problems relating to clinical

supervision.

Clear frameworks for supervision practice should be

identified.

References

Barber P. & Norman L. (1987) Skills in supervision. Nursing

Times 83 (2), 3–4.

Butterworth T. & Faugier J. (1992) Clinical Supervision and

Mentorship in Nursing. Chapman & Hall, London.

Coombes R. (1996) Nurses blow the whistle on years of alleged

bullying. Nursing Times 92 (51), 5.

Coombes R. (1997) Breach of trust. Nursing Times 93 (1), 15.

Darbyshire P. (1993) In the hall of mirrors. Nursing Times

December 49.

Darley M. (1995) Clinical supervision: the view from the top.

Nursing Management 2 (3), 14–15.

Elcock K. (1997) Reflections on being therapeutic and reflection.

Nursing in Critical Care 2 (3), 138–143.

Faugier J. & Butterworth T. (1994) Clinical Supervision: a Posi-

tion Paper. School of Nursing Studies. University of Manche-

ster, Manchester.

Hall I.B. (1996) Pursuing excellence. Journal of Community

Nursing 10 (5), 35–36.

Heath H. (1997) Keeping a reflective practice diary: a practical

guide. Nurse Education Today 18, 592–598.

Heron J. (1990) Helping the Client: a Creative Practical Guide.

Sage publications, London.

Heron J. (1996) Co-Operative Inquiry: Research Into the Human

Condition. Sage, London.

Hingley P. & Harris P. (1986) Lowering the tension. Nursing

Times August 52–53.

HMSO (1988) Community Care: Agenda for Action. HMSO,

London.

HMSO (1989) Working for Patients and Caring for People.

HMSO, London.

Houston G. (1990) Supervision and Counselling. The Rochester

Foundation, London.

Hull C. & Redfern L. (1996) Profiles and Portfolios: a Guide for

Nurses and Midwives. Macmillan, London.

Johns C. (1998) Opening the doors of perception, In Trans-

forming Nursing Through Reflective Practice (C. Johns & D.

Freshwater eds), pp. 1–20. Blackwell Science, London.

Johns C. (2000) Becoming a Reflective Practitioner: A reflective

and Holistic Approach to Clinical Nursing, Practice Develop-

ment and Clinical Supervision. Blackwell Scientific Publica-

tions, Oxford.

Johns C. & Freshwater D. (1998) Transforming Nursing Through

Reflective Practice. Blackwell Scientific Publications, Oxford.

Johns C. (1994) Guided reflection. In Reflective Practice in

Nursing: The Growth of the Professional Practitioner (A. Pal-

mer, S. Burns & C. Bulman eds), pp. 110–130. Blackwell

Scientific Publications, London.

Jones A. (1998) Clinical supervision with community Macmillan

nurses: some theoretical suppositions and case work reports.

European Journal of Cancer Care 7, 63–69.

Kaberry S. (1992) Supervision-support for nurses. Senior Nurse

12 (5), 38–40.

Lees C. (1999) Clinical supervision – an initial evaluation. Journal

of Community Nursing 13 (6), 14–16.

Lowry M. (1998) Clinical supervision for the development of

nursing practice. British Journal of Nursing 7 (9), 553–558.

Marrow C.E., Macauley D.M. & Crumbie A. (1997) Promoting

reflective practice through structured clinical supervision.

Journal of Nursing Management, 5 (2), 77–82.

Marrow C.E. & Yaseen T. (1998) Developing supervision in

adult/general nursing. In Clinical Supervision and Mentorship

in Nursing, 2nd edn. (T. Butterworth, J. Faugier, & P. Burnard

eds), pp. 95–112. Stanley Thornes Publications, Cheltenham.



McCallion H. & Baxter T. (1995) Clinical supervision take it

from the top. Nursing Management 1 (10), 9.

McCulman J. & Paton R.A. (1992) Change Management: a

Guide to Effective Implementation. Chapman, London.

Meehan F. (1997) NHS bullies win. Journal of Community

Nursing, Editorial, 11(2).

Olsson A., Bjorkhem K. & Hallberg I.R. (1998) Systematic clin-

ical supervision of home carers working in the care of demented

patients at home: structure, content and effect as experienced

by participants. Journal of Nursing Management 6 (4),

239–246.

Pesut D.J. & Williams C.A. (1990) The nature of clinical super-

vision in psychiatric nursing: a survey of clinical specialists.

Archives of Psychiatric Nursing 4 (3), 188–194.

Reid B. (1993) �But we�re doing it already!’ Exploring a response

to the concept of reflective practice in order to improve its

facilitation. Nurse Education Today 13, 305–309.

Royal College of Nursing (1998) Guidance for nurses on clinical

governance. RCN, London.

Severinsson E.I. & Borgenhammer E.V. (1997) Expert views on

clinical supervision: a study based on interviews. Journal of

Nursing Management 5, 175–178.

Skoberne M. (1996) Supervision in nursing: my experience and

views. Journal of Nursing Management 4, 289–295.

Stoltenberg C.D. & Delworth U. (1987) Supervising Counselors

and Therapists. Josey Bass, San Francisco.

Wright B. (1993) Clinical supervision. Accident and Emergency

Nursing 1 (4), 181–182.

C. E. Marrow et al.


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