Clinical supervision as a model for clinical leadership
CHRISTOPHER JOHNS P h D , R N
Reader in Advanced Nursing Practice, University of Luton, Bedfordshire, UK
Introduction
Clinical leadership is acknowledged as a cornerstone for
the development for nursing and health care practice in
successive Government strategy documents – Vision for
the Future (NHS Management Executive [NHSME]
1993) and Making a Difference (Department of Health
[DoH] 1999). These strategy documents set a back-
ground for a new NHS that has a strong vision and
commitment, is responsive to innovation and change,
with a strong nursing leadership. Alongside this Gov-
ernment agenda is a contemporary literature that sug-
gests the nature of nursing leadership needs to change in
order for nursing to make a meaningful contribution
within organizations and assert a nursing agenda
(Vladeck 1992, Schuster 1994). Or put another way, a
leadership that is adequately prepared to respond posi-
tively and effectively to both Government and profes-
sional agendas. As Sofarelli and Brown (1998) note in
reviewing the transformational leadership literature:
�A transformational leader will provide the skills
for the profession to stretch its boundaries and be
innovative in the way in which problems are
viewed and solved … and will move nursing
further into the centre of the arena of health care
services�. (p. 203)
Transformation is to change the nature of something.
Authors such as Barker and Young (1994) and Klakovich
(1994) view the transformational leader as someone to
lead or liberate nursing from the dark shadows of patri-
archy and oppression so nursing can assert and fulfil its
own agenda in collaborative ways within the organiza-
tion. This position suggests that nursing leadership has
failed to achieve this, both being viewed and viewing itself
as a subordinate and powerless workforce whose agenda
is set and controlled by more powerful others. While the
idea of transformational leadership is espoused as an ideal
within the nursing literature, it does not mean it is desir-
able within health care organizations despite the Gov-
ernment rhetoric. Indeed, transformation of nursing must
inevitably mean transformation of the organization itself
as it accommodates new patterns of relationships. Indeed,
it is likely that the organization, whilst paying lip service to
transformational leadership, will covertly resist it because
of the inherent threat to established patterns of relating.
Besides targeting clinical leadership, the �Vision for the
Future� document (NHSME 1993) also targeted the
development of clinical supervision as a means to enable
Correspondence
Christopher Johns
4 High Street
Riseley
Bedfordshire MK44 1 DU
UK
E-mail: [email protected]
J O H N S C. (2003) Journal of Nursing Management 11, 25–34
Clinical supervision as a model for clinical leadership
Clinical leadership and clinical supervision are topical areas of nursing develop-
ment. A project was established to facilitate the growth of leadership ability with a
group of ward sisters through individual clinical supervision. The work revealedthat ward mangers struggled to fulfil their leadership roles largely because of
embodied ways of relating within a prevailing organizational culture that
constrained them. The paper also reflects on the impact of supervision todevelop leadership practice.
Keywords: clinical supervision, leadership, organization, transformation, ward managers
Accepted for publication: 18 April 2002
Journal of Nursing Management, 2003, 11, 25–34
ª 2003 Blackwell Publishing Ltd 25
practitioners to accept responsibility for developing and
sustaining effective practice and safeguarding patient
care. As such clinical supervision might be viewed as a
developmental process to enable the growth of clinical
leadership at ward manager level. As Making a Differ-
ence (DoH 1999) notes �ward managers have a pivotal
role in NHS Organizations� (p. 53), and were therefore a
key focus for developing leadership.
The contemporary leadership literature espouses a
transformational leadership style required to respond to a
postindustrial paradigm (Rost 1994). Examples of this new
transformational style are found in business (Schuster
1994), in health care (Trofino 1995), nursing (Sofarelli &
Brow 1998, Dunham & Klafehn 1990). Trofino (1995)
makes the distinction between a transactional and trans-
formational leadership style. The transactional style is
functional towards achieving a specific outcome based on
an exchange system that the follower values. The transfor-
mational style is based on relationship where people work
together towards realizing shared vision and shared success,
both personal and organizational. Such a leadership style is
motivating and energizing for both leaders and followers.
The transactional leadership style tends to be characterized
by an emphasis on positional, reward and sanction types of
power, whereas the transformational leadership style is
characterized more by relational and expert types of power
(French & Raven 1968). The consequence is a fundamental
shift of the way power is used within organizations.
Transformational leadership views all experience as
opportunity for learning. As such the organization
becomes reflective, establishing what Senge (1990) calls
the learning organization; an organization that is more
holistic, flexible, responsive, proactive, and caring. In
other words, it is an organization that lives its values and
works hard to identify and resolve contradictions
between its values and its practice. Reflection is the core
of clinical supervision (Bond & Holland 1998, Rolfe
et al. 2001), suggesting that clinical supervision may
provide a congruent learning opportunity to develop
transformational leaders within nursing.
Research aim
In response I established a study to implement and evaluate
the impact of clinical supervision in facilitating the growth
of the clinical leaders’ leadership ability within the medical
and elderly care directorate of a large general hospital.
Sample
Initially [what I described as Phase 1] I contracted with
nine ward managers to enter into individual clinical
supervision with the explicit aim of facilitating their
clinical leadership role (3 �H� grade; 5 �G� grade; 1 �F�grade). The ward managers, or who I shall refer to as
�leaders�, accepted my invitation to participate in the
project following a project presentation. Six months
later, an H grade ward manager from the surgical
directorate was recruited for the project on the condition
that she simultaneously supervised two �G� grade ward
managers in the surgical directorate, again with the
explicit aim of facilitating their clinical leadership role
(Phase 2). She also contracted with a �D� grade staff nurse
on her own ward. None of the contracted leaders had
previously experienced clinical supervision. All the ward
managers were female.
Method
In both phases of the project, we agreed to meet for
clinical supervision for 1 hour every 21 days. This would
total 15 sessions over a 12-month period. However, in
Phase 1, the exigencies of everyday practice determined a
different schedule that could not have been predicted.
The practitioners agreed to bring everyday experiences to
reflect on that they felt were significant in fulfilling their
leadership role. Reflection enables practitioners to sur-
face, confront, and work towards resolving contradic-
tions between the way he/she practised and what is
desirable in terms of effective leadership (Johns 1998).
Kieffer (1984) highlights the significance of revealing
contradiction as a catalyst for empowering self towards
realizing self’s best interests and the crucial role of an
external enabler to support and challenge the person
through the developmental process. As the clinical
supervisor, I was conscious not to impose my own
interpretations on their experiences. Clearly, it was
important to establish the conditions of trust so the
practitioners felt safe to disclose their experiences. Just
because collaboration is espoused, does not mean we were
able to participate on equal terms in practice. Collabora-
tion had to be actively constructed within the relationship
as an explicit aspect of the learning process (Webb 1990).
This was, in itself, a significant aspect of learning, because
we assumed that the effective clinical leader is someone
with a strong sense of self, who accepts responsibility for
self, is assertive and able to establish collaborative rela-
tionships as far as possible with other health care workers.
Evaluative approach
To evaluate the development of leadership, I developed
the clinical leadership template. The template adopts a
functional approach to defining the clinical leadership
C. Johns
26 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34
role. It consists of eight core leadership roles that were
agreed with clinical leader as representative of their
leadership role. Discussing and agreeing the template
was helpful for the clinical leaders to become aware of
their leadership roles and the extent they currently
fulfilled it. The template (Figure 1) was itself tested and
transformed within the research process to more ade-
quately represent the leadership role.
During each session I recorded the dialogue
between myself and each practitioner. These notes
were word-processed within 24 hours and given to
each practitioner for their agreement. These were
generally acknowledged as accurate. As one H grade
(Delia) commented �The notes were absolutely right,
very accurate�. Each subsequent session commenced
by picking the issues from the previous session. Did
the leader take action as anticipated? What happened
as a consequence? What factors constrained action?
The notes built session by session as an unfolding
reflexive narrative to reveal its subtlety and uniqueness,
and those factors that had constrained the practitioner in
realizing effective clinical leadership. Interspersed between
the dialogue, I wrote interpretative summaries that plotted
the growth of leadership. The narrative approach
respected and highlighted the way each leader responded
to the opportunity to develop their leadership role through
clinical supervision. Each practitioner was given a pseud-
onym which are used within this paper (Table 1).
A meta-analysis of the narratives revealed and dis-
cussed the factors that seemed to constrain the realiza-
tion of leadership potential within each aspect of the
clinical leadership role (Figure 1). These issues are dis-
cussed.
Findings
The majority of experiences the clinical leaders shared
were characterized by anxiety and conflict, and with
negative feelings such as anger, frustration, guilt and
despair. Few experiences indicated their satisfaction with
work. I was conscious that the overwhelming negative
focus of experiences may skew the narratives as repre-
senting lives as generally problematic, yet in terms of
realizing clinical leadership this did seem true.
Developing a vision for practice
Managing vision is central to transformational leadership
(Senge 1990, Sofarelli & Brown 1998). Vision gives
meaning and direction to practice and unites staff in
common purpose. Without exception, the practitioners
lacked a clear vision for practice despite written �ward
philosophies�. However, these emerged as little more that
than vague statements that had little practical meaning. As
reflected in the way the leaders talked about their work,
they tended to define work and themselves from a func-
tional perspective. When challenged they struggled to
conceptualize practice in terms of values. For example,
when Tessa became a G grade I challenged her to reflect on
ward values at her first team meeting. However, she felt it
was more important to focus on �the little things, such as
patients having a glass of water at hand�; typifying the
prevailing functional perspective. Given the centrality of
vision to leadership role, only two practitioners
reconstructed their philosophies for practice in meaning-
ful ways to focus nursing practice and development. In
defence, the practitioners justified their passivity to create
meaningful vision in terms of being locked into a medical
model that defined caring and felt unable or were reluc-
tant to assert a nursing identity.
Maintains expert clinical credibility
Perhaps one reason that the practitioners did not easily
engage the idea of vision was that they felt they had become
increasingly remote from everyday clinical practice
reflected in the fact that few of shared experiences were
grounded in clinical experiences with patients and families.
One consequence was that they were not so available to
lead by example. Their lives revolved around managerial
issues. It was an area of considerable frustration because
they all wanted to be more involved in direct patient care.
Two of the H grades viewed their future in management
Develops and maintains avalid vision for practice
Maintains expert clinical credibility Ensures the overall quality of care
Manages self to maintain charismaand effectiveness
Clinical leadership role
Facilitates staff to fulfil role responsibility
Facilitates the development of clinical practice
Facilitates the development and support of staff competence
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
Figure 1Clinical leadership template
Clinical supervision
ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34 27
and felt less dissonance in their role than some of the other
leaders who were struggling with their loss of �caring� role.
Beattie, one of these two H grades, perceived her staff felt
that she had no clinical role at all which led to conflict with
her senior ward staff about who actually managed clinical
practice. The lack of visible clinical role undermined the
leader’s expert and relational sources of power (French &
Raven 1968). As a consequence, more authoritative sour-
ces of power, such as positional power, were emphasized
that constrained the development of collaborative
relationships viewed as central to transformational lea-
dership (Sofarelli & Brown 1998). Some leaders, notably
the H grades, successfully devised strategies to increase the
percentage of their time devoted to clinical practice, lead-
ing to a marked improvement in personal satisfaction and
perception of self as leader (rather than manager). In other
words, they perceived that clinical leaders have strong
clinical roles.
The experiences of clinical practice that were shared
were profound and led to very significant personal and
practice development. For example, Shirley disclosed:
�A daughter of a woman who had had a biopsy of
pancreas as a day case stopped me in the corridor.
She said – ‘‘I don�t want my mother told about her
diagnosis’’. She was really quite distressed about
the whole thing. The situation lasted about
2 minutes. I know I let her go home feeling upset.
The consultant had told her that her mother most
likely had inoperable cancer. She felt her mother
was not strong enough to know. The consultant
didn’t want her mother to know until he had
definite diagnosis. I said something like ‘‘that’s a
possible barrier between you – you knowing but
your mother not knowing’’. I intuitively wanted to
touch her but didn’t do this. I certainly won’t see
her again – she would not come to my ward if
readmitted. I wanted to phone her up to relay my
concern and show support. I thought about it all
day. I was upset by it.’
Sharing such experiences helped the leaders to become
aware of self and ward practice. It was deeply felt and led
to significant shifts in personal and practice perspectives
(Johns & Graham 1996).
Facilitates the growth of staff into appropriate
role responsibility
One area of practice that seemed to cause considerable
frustration for all the ward mangers was the feeling that
their staff were not responsible. In response they tended,
to varying extent, to respond from a �parental-hierarchy�stance. By this I mean the leader was both the critical and
protective mother to the naughty and suffering staff.
Whilst the leader might chide the child’s lack of
responsibility, she was also protective. I termed this
�misplaced concern� because it did not tackle issues. The
outcome was an anxious dependency on the part of the
staff. The leader resisted letting go of this parental stance
because she was profoundly anxious about her own ac-
countability. The stance of the critical-protective mother
was the major barrier to facilitating development of staff
into role responsibility. Whilst they were frustrated at the
refusal of their staff to accept responsibility, especially
for poor care and managerial tasks, they were also
reluctant to confront staff within a prevailing culture of
conflict avoidance. If they did confront they experienced
considerable anxiety.
For example, Bertha [session 4] said:
�I�ve delegated to people in the past, for example
with mouth care and using toothbrushes and
toothpaste rather than foam sticks. This staff
nurse was enthusiastic but then she’s done nothing
about it! I feel that I give them the responsibility
but its still mine! I should have carried on about it
to her.’
Bertha reflected her anxiety that the responsibility was
still hers. She knew the organization would hold her to
account not the staff nurse. This anxiety was heightened
within a blame–shame organizational culture, where
anxiety was transmitted down the organization to the
ward sister. The result was that Bertha was stuck within
this tension, anxious to control her environment, and yet
anxious to let others develop responsibility. In a later
supervision session, Bertha later shared an experience
about complaints she felt were caused by two staff
nurses’ irresponsibility. I noted in her narrative:
�Bertha needed to manage the transmitted anxiety
from the organization in terms of any formal
complaint. Hence the risk was to project this
embodied anxiety into the cause – the two staff
nurses as being irresponsible – as a critical mother
ranting at her naughty children. Yet she doesn�tbecause she wanted to avoid her personal dis-
comfort of ensuing conflict. So the issue was
Table 1 Practitioner Pseudonyms
H grades G grades F grade D grade
Delia Carol Caitlin JennyVera AgnesBeattie ReneShirley Tessa*
BerthaClaireSaskia
*Tessa became a G grade during the project.
C. Johns
28 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34
avoided – which fuels Bertha’s sense of discomfort
because she knew she needed to take action – yet
supportive action rather than perpetuate the
‘‘blame’’ culture even as she was blamed for the
ward’s poor practice that led to the complaint.’
The �parental-hierarchical� stance was a major con-
straint on developing the transformational leader.
Unlearning this anxiety and way of responding was
clearly an important aspect of our work together
(Mezirow 1981, Kemmis 1985). Yet, it was difficult
work because the parental way of responding was con-
stantly reinforced in patterns of communicating with
more senior staff. Change needed to take place at a
higher level between ward sisters and management in
order to break out of a self-reinforcing cycle.
Facilitates the development and support of staffcompetence
In guiding Shirley through her experience with the
daughter I asked her:
�Can you use this experience positively by sharing
it with staff to raise profound caring issues – do
we value this type of care? How can we make it
happen? This would also role model sharing
feelings and reflective practice for others to relate
to and share feelings.�Shirley responded
�This would be difficult for me.�However she did, reflecting the empowering impact of
supervision. Shirley said
�Other staff, one after another related to this
experience with their own distressing and frus-
trating experiences – they recognized the need to
talk about how we feel about our patients.�As with Shirley, I challenged all ward managers to open
dialogue with their staff around practice issues as a mu-
tual process of development and support. As Shirley’s
words represent, staff did not perceive themselves to be
competent with many aspects of care associated with their
patients or their own feelings. Shirley had been reluctant
to disclose herself to her staff because she felt it would
undermine her authority in revealing her own lack of
competence. I confronted this perception of self, that it in
fact encouraged others to hide behind illusions of self as
competent and reinforced a culture that good nurses cope.
My approach to supervision was exactly this – to chal-
lenge and support practitioners to develop and sustain
competence. Hence, I confronted all ward managers with
the way they achieved this. In response many began to
de-brief particular situations with staff and to even to
explore implementing supervision into their units.
However, this part of role was generally poorly developed
and unresponsive to development.
Facilitates the development of clinical practice
The leaders talked about developing practice. Some, like
Shirley, explored practice development in relation to
specific experiences. Others took a more objective view
talking about practice development as a particular con-
cept. One reason to talk objectively was to avoid talking
about self. The narratives are filled with the leaders’
plans to implement new ways of working self-medica-
tion, different models of nursing, and other such initia-
tives. As I have noted, Bertha talked about implementing
toothbrushes with mouth care. Yet, whilst managers
talked about these things they did not seem to have either
the authority or inertia to carry these ideas forward. As
such, changing the conditions of practice to accommo-
date new ideas and exercise leadership was difficult work
because normal ways of perceiving and responding
within situations seemed to be shaped through the
interests of more powerful others, rather than what
might be described as nursing interests. The organization
had no clinical practice development nurses in post. As a
consequence, the leaders lacked support and information
about these ideas. Except for the two managers who had
recently undertaken degree or postgraduate study, the
others expressed a strong anti-intellectual bias and felt
overwhelmed with theoretical papers offered to them in
supervision. Their managers were not nurses, although
some had been nurses in past lives, who expressed little
interest in clinical issues unless it became a problem. Then
a reactive remedial stance to practice development was
imposed. The leaders complained about the amount of
organizational stuff being passed down to them as part of
their roles in becoming ward managers. In general, they
resisted the expansion of their roles although complied
reluctantly. In response they said they lacked time for
practice development. Where the leaders did attempt
change, for example, Delia’s efforts to implement team
nursing, they seem ill equipped to manage change because
it led to change conflict. The need to avoid conflict was
pervasive amongst the leaders although avoidance of
change tended to be rationalized in parental terms – that
the staff were stressed enough or as Tessa put it:
�Staff can�t be expected to use their own time.’
Ensures the overall quality of care
Often, the focus for sharing an experience was a com-
plaint. It was interesting to speculate which was the
greater motivating factor – the commitment to caring or
Clinical supervision
ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34 29
the avoidance of potential complaint? I wrote in Tessa’s
narrative:
�She noted the spectre of complaints, reflecting the
overwhelming attitude of the organization to
minimize complaint. Tessa noted – I can�t ever be
rude. I always need to calm potential complaint
situations down.’
Anxiety about complaints was transmitted through an
organizational hierarchy. Yet the need to avoid complaint
reflected a reactive attitude to assuring quality. In fact,
there were no formal methods for monitoring quality of
care at ward level. No managers were involved in standard
setting. Neither were organizational methods to monitor
quality of care apparent, perhaps reflecting why quality of
care was not perceived to be an everyday issue that man-
agers should concern themselves with.
Manages the unit effectively
The majority of shared experiences reflected the ward
managers’ over-riding concern to manage everyday issues
that cropped up such as shortage and recruitment of staff,
covering shifts, managing a tight budget, responding to
the agendas of managers and doctors, meetings, filling in
questionable forms, and difficult situations that con-
cerned patients. Supervision often felt like reactive trou-
ble-shooting rather than a systematic development of
leadership. The supervisory effort was to take control of
the everyday and yet such control was elusive. No wonder
issues of leadership felt remote. Just getting by with these
issues was a major task that created considerable anxiety.
Many of the narratives reflect a sense of merry-go-round
as the same issues repeatedly emerge without the leaders
being able to move beyond the root of their anxieties. As
Shirley noted in her supervision of Saskia:
�I get so frustrated because Saskia can�t take con-
trol of some situations. She’s reflecting on the
same old thing over and over again and getting
nowhere!!’
Supervision was just 1 hour every 4 weeks and
between times the leaders felt they sunk back into
existing patterns of seeing and responding to practice.
The organization expected the primary role of man-
agers was to manage the smooth running of the organi-
zation rather than lead the development of nursing. As
Freidson (1970) noted, the primary attention to its own
smooth running is the hallmark of bureaucratic organi-
zations. Nursing seemed to have no political kudos. It was
a workforce that had internalized a strong sense of the
subordinate and powerless self. The manager’s agendas
were set by the organization, which, as I have noted, gave
the managers, no sense of autonomy to act.
Establishing effective working relationshipsnecessary to achieve effective practice
Transformational leadership is characterized by trusting
and collaborative relationships between colleagues at all
levels of the organization. In contrast, the leaders’ expe-
riences revealed a culture of conflict and conflict avoid-
ance. Without doubt, the management of everyday care
was the management of conflict that seemed to infect
every part of practice resulting in the many negative
feelings the leaders expressed. Whilst reflection helped the
nurse to understand conflict, resolving conflict was less
easily achieved because of learnt ways of responding to
situations through avoidance because conflict was
uncomfortable. This understanding fits with Cavanagh’s
(1991) observation that the avoidance was the predomi-
nant style of nurse managers in managing conflict. It
seemed that the leaders had learnt to be docile. Asserting
their own views was difficult because they felt they lacked
a powerful enough voice and feared sanction. As Shirley
demonstrated, when she did learn to challenge her man-
ager, the fear of sanction was exposed as illusionary as if
the fear had been internalized as a self-regulatory process,
what Foucault (1979) describes as the governed body. For
example, Claires’ narrative is dominated by her theme of
conflict with a particular consultant. I wrote in her nar-
rative at the end of the first 12 months:
�Claire had been socialized as a nurse to respond
in certain ways to consultant doctors. Her struggle
to assert herself with the consultant is a constant
theme. The consultant responded to Claire as if
she was subordinate. Claire struggled to resist this
power inequality.�Perhaps, it would be easier for practitioners such as
Clare to rationalize and maintain the status quo in order
to live harmonious lives and the patronage of more
powerful others. As Smyth (1987) noted:
�Most of us, unless we feel uncomfortable, shaken
or forced to look at ourselves and our circum-
stances, are unlikely to change. It is far easier to
accept our current conditions and adopt the line of
least resistance.� (p. 40)
This is perhaps more true working in bureaucratic set-
tings that has taught nurses to be passive and compliant
(Lieberman 1989). Accepting the truth-value of this
statement suggests that exposing contradiction and con-
flict in everyday practice, and working with practitioners
towards a sense of �empowerment� will create tension
within the organization. Yet, as Shirley illustrated, the
more she claimed leadership the more influential she
became within the organization. Indeed the organization
came to value her more, casting doubt on the idea that the
C. Johns
30 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34
organization would resist nursing empowerment. Rather it
did to an extent, yet once its value was shown, it could not
resist nursing leadership because its value to the
organization was irresistible. Her leadership was non-
threatening because it was grounded in collaborative
intent. In contrast, Beattie saw herself as a manager and her
experiences were focused on imposing control over her
directorate rather than developing clinical leadership. In
other words, she had largely absorbed the prevailing
management attitude. This was a significant observation
because all practitioners sought to assert control over their
practice environments and needed to achieve this before
they could develop clinical practice.
Manages self to maintain charismaand effectiveness
Charisma is the quality of leadership that attracts and
influences followers. It is essentially concerned with rela-
tional rather than positional power (French & Raven
1968). Whilst some of the ward managers had charismatic
qualities, I tended to be submerged under an everyday
pressure of getting by. The leaders revealed themselves as
an anxious and tired group battling against the odds with
low establishments, high sickness, high work-loads, high
organizational expectations, a lack of organizational sup-
port and without adequate support systems. Indeed they
did not feel valued or cared for by the organization. Moral
and energy was low yet their loyalty and resolve to win
through at times felt astonishing.
The leaders did not have strong supportive networks.
Beattie and Vera met daily and talked through work issues.
She and others felt isolated. Carol even felt abandoned.
For some, clinical supervision emerged as a supportive
and developmental opportunity although it undoubtedly
felt like an added pressure because it forced them to look
into the mirror to review themselves as clinical leaders
when they might prefer a more quiet and conformist life.
As Jenny noted:
�I feel that if I do become stressed I have a means
of releasing it through supervision. I don�t know
what would have done if I had not had the
opportunity to reflect! After each session I feel a
weight of my shoulders, even if certain things are
said that I don’t want to hear, it still inspired me
to pick myself up and get on with it.’
Clinical supervision as a developmental process
The reader is directed to the individual narratives to gauge
the significance of the work for each individual leader. In
general, the above discussion reflects clinical supervision
as a weak model for facilitating clinical leadership, at least
in the way it was constructed within the project. Its
strength was as a problem solving tool that guided the
leader to focus positively on resolving everyday problems.
As a method of shifting the leaders from transactional to
transformational leadership, clinical supervision proved
to be limited because the factors that constrained leaders
were deeply embodied and embedded within normal pat-
terns of relating. The leaders emerged as a relatively weak
professional group in contrast with managers and doctors.
From this perspective it is important to consider if the
developmental process was flawed or the project expec-
tations too great. In responding to this challenge, five
factors emerge as significant:
• the organizational culture was unsympathetic;
• establishing unrealistic expectations and pressure;
• developmental time frame was inadequate;
• individual supervision limited developmental poten-
tial; and
• guidance skills were inadequate.
The organizational culture was unsympathetic
The individual narratives indicate that the practitioners
struggled to fulfil the clinical leadership roles within an
organizational culture that was unable to accommodate
such growth despite management rhetoric to the con-
trary. The research unearthed cultural and organizational
factors that constrained the development of clinical
leadership. Even when these constraining forces were
understood it was very difficult to shift them to accom-
modate effective clinical leadership because they were so
deeply embodied within practitioners and embedded in
�normal� practice reinforced in normal ways of relating
between people.
Inevitably, the focus on anxiety gave a distorted pic-
ture of the practitioners’ overall experience. They com-
mented on this fact quite strongly when they read the
narratives. It was perhaps too easy to focus on the dif-
ficulties that faced them. This needs to be put into con-
text. The narratives were a celebration of considerable
effort towards creating the conditions whereby practi-
tioners could begin to focus on clinical leadership. They
could understand themselves in the context of this role
even though they could not so easily feel empowered and
take action to change these conditions necessary to
become effective clinical leaders. As Fay (1987) has
highlighted embodiment, tradition and authority are
powerful barriers to rational change.
However, one of the strongest images to emerge from
the work was the opportunity for the nurses to voice
their concerns. As Saskia noted:
Clinical supervision
ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34 31
�Supervision gave me somewhere to voice my
concerns. It allowed me to say out loud or rather
encouraged me to recognize some of my short-
comings. Very hard to accept.�Many other comments echo this sentiment. Voice was
a metaphor for empowerment (Belenky et al. 1986,
Johns & Hardy 1998). The development of an informed
and assertive voice was a significant focus for develop-
ment that acknowledged that change of self and change
of practice is a social process over time. As Delia noted
after 11 sessions:
�I came out (of the sessions) keen to get on with all
the things we talked about and then got taken
over by other issues and then there was the next
session and I hadn�t done all those things. I feel I
have been very slow about it you have had to
labour points very slowly with me. I felt it was a
good thing to do but I felt it took a long time to
get into the way of it. I don’t think I am set in my
ways. Really you don’t talk to anybody else about
these things – you don’t discuss your own failings,
feelings or achievements with anybody else.’
This comment reflects both a culture of limited
on-going development or support within their ever
changing ward sister roles and the way clinical supervi-
sion opened up a new space of learning. As such, it was
important to acknowledge development in terms of
knowing self and empowerment rather than (simply) in
terms of concrete changes in practice.
Time was perceived as a major barrier to implementing
supervision as part of everyday practice. It was not easily
accommodated within a practice world already over-
stretched with competing activities that were generally
perceived as a greater priority as reflected in the pattern
of cancelled appointments that inevitably weakened the
developmental opportunity. I was left with a strong
impression that the ward manager’s key organizational
role was to contain chaos. Whilst managing chaos might
be construed as a creative edge, in reality the ward
managers were driven onto a reactive backfoot that left
room to manoeuvre the space to be proactive in terms of
leadership development. Hence, whilst this work offers
insight into the impact of implementing supervision into
the everyday lives of this group of nurses, it also raises
the question – �how can supervision be accommodated at
a meaningful and practical level? It is pertinent to inquire
if the �real� agenda of supervision will be to enable and
empower nurses to realize their visions of nursing, or
whether it will become a surveillance system to ensure an
efficient and docile workforce? (Johns 2001). As an
external agent to the organization and a committed col-
laborative researcher I had no organizational agenda to
grind, although I was conscious of focusing the practi-
tioners on their caring role which I felt was buried under
a heap of managerial concerns. My agenda was, in Fay’s
(1987) terms, to enlighten, empower and emancipate
them to realize their leadership role. However, it was
important for me not to see that goal as my responsi-
bility. My responsibility was to ensure the developmental
process.
Establishing unrealistic expectations and pressure
My role as a clinical supervisor was to both challenge
and support the leaders. The effort of constantly
asserting caring beliefs and clinical development within a
general unsympathetic environment was unsettling and
at times threatening for the practitioners. Hence, a key
role of my supervision was to focus the practitioner not
to perceive herself as a failure when she could not act as
she felt she should do based on new insights. Otherwise
the risk is to hurtle them into walls of unattainable
expectations and increased frustration and potential
personal crisis. Indeed, some of the nurses quit the pro-
gramme because it was too painful to continue this work
at this time. Yet, this frustration already existed, felt as
some deep gnawing within self. Exposing this deep
frustration was a fine line I had to balance. In response to
Caitlin’s sense of being overwhelmed I said:
�I feel more like a counsellor today than a super-
visor. Someone to unburden to. Perhaps hospitals
should have counsellors for people like you to
have this sort of conversation.�Certainly, some practitioners did feel hurtled against
brick walls. Whilst supervision was supportive and
enabled the practitioners to focus positively on issues, it
also exposed their lack of competence to take effective
action. Some lived and learnt through this whilst others,
such as Rene and Tessa, buckled under the strain. Their
respective narratives reflected how they lacked support in
everyday practice when faced with great stress. Rene had
entered the project in a state of crisis. Supervision had
pulled her out of the stream yet Rene was unable to
change the conditions in her practice, which led her to
repeatedly fall in time and time again. To extend the
metaphor, Tessa could not learn to �think upstream�(Butterfield 1990), and eventually she drowned. Tessa
was in crisis in session 11. In her notes I wrote:
�Why did the organization allow this most talented
and caring person to be so distressed? Why was it
intent on destroying her? Because the organization
itself tried to cope, it looked inwards at itself and
its own survival. It couldn�t afford to acknowledge
Tessa’s experience as valid. Tessa was just a
replaceable victim in a system that did not
C. Johns
32 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34
acknowledge individuals. Tessa said: ‘‘Will you
visit me in hospital?’’’
Tessa did not make another appointment – an ironic
twist that at the time she most needed support she shunned
it because it is too painful. Ironically, I noted that perhaps
we should increase our supervision to increase her sup-
port. Without doubt, the research process put pressure on
the practitioners to pay attention to their clinical leader-
ship role that they had not previously considered. For
example, at the beginning of session 5 Bertha said:
�I felt totally depressed after the last session
because you make me do more things than pos-
sibly can be done. But I want to do them!�In contrast Delia felt supervision inspired her. She
noted:
�Each time we had a session I felt positive even if I
came feeling negative, although I don�t know how
long that lasted.’
Developmental time frame was inadequate
Although clinical supervision was contracted as a 1 hour
session every 3 weeks, in Phase 1, the average time span
between sessions was 5 weeks, reflecting the way sessions
were cancelled because of various pressures. For example,
the time span between Delia’s session 4 and 5 was
84 days. She said �I�m trying to sort myself out from so
long ago. I’m awfully sorry, time does make a difference.’
I asked �Has supervision just slipped away?� Delia
responded �It has. Other things have come to the fore.
I haven�t thought about it much recently. I have let it go’,
I challenged �It didn�t make much impact then?’ Delia
replied �I now realize you do need the ongoing discussion.
I can see why you do it every 3 weeks. You need to keep
that impetus. You�ve only got to have one relapse. I
couldn’t make that session and then made a mistake to
agree the next one. And things just piled up on top.’ I
responded �How can we ensure we meet more frequently?
Unfortunately, such lapses in the frequency of sessions
was not unusual. As a consequence, Delia and I only met
11 times instead of 15. In contrast, in Phase 2 we met on
average every 24 days over a 24-month period. Phase 2
was extended for a second year because we felt a greater
longitudinal study would give deeper insights into the
developmental trajectory. The reason for the difference
in session frequency between the two phases was the
commitment of Shirley, the H grade ward manager from
the surgical directorate. Despite the greater commitment
and frequency of sessions, Saskia and Clare�s leadership
development was no more developed than the Phase 1
leaders. The overall work illustrated that the develop-
ment and sustaining of leadership expertise must become
a cultural norm.
Individual supervision limited developmental potential
Since the study was carried out, initiatives such as
clinical audit and clinical governance have been
implemented although the extent such initiatives
can help leaders emerge from a culture of non-authority
and inertia remain to be seen. Leadership initiatives
such as LEO and the RCN leadership programme help
to promote and support leadership as an organizational
initiative, whereby the success of these initiatives will be
a reflection of the organization itself. The RCN lead-
ership programme is currently being held at the research
hospital. The �leaders� meet weekly in both individual
supervision with the group facilitator and in group
learning sets. On reflection, the supervision project may
have benefited from group sessions to bring the leaders
together and counter the sense of being isolated. Within
the individual sessions they remained isolated.
Being in groups may have also been mutually
empowering and created a supportive networks in prac-
tice. In contrast, the clinical supervision project was
locally negotiated with the Directorate senior nurses who
participated in the programme. As such it was invisible at
an organizational level. This point suggests that despite
the rhetoric of clinical supervision being essentially a
professional initiative, its success will depend on orga-
nizational support.
Guidance skills were inadequate
Of course this is an impossible question to answer
because I was deeply embedded within the project.
However, the dialogue within the individual narratives
makes the supervision process transparent and thus
makes possible an analysis of the facilitation process.
Clearly, the success of such intensive facilitation tech-
niques are dependent on facilitation skills.
Conclusion
Clinical supervision was established as a developmental
opportunity to develop clinical leadership and was con-
strained by the organizational culture. The leaders
involved in the project were willing yet generally unable
to significantly develop their leadership ability. On a
positive note, the learning opportunity increased over
time, as evident with Shirley and the narratives of the
three ward managers she supervised. These practitioners
learnt to value, prioritize, and accommodate supervision
reflected in very few cancelled sessions.
To accommodate supervision would seem to require
overt organizational support but without becoming an
overt organizational requirement. The analysis revealed
the nature of these constraints which were deeply
Clinical supervision
ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34 33
embodied within the leaders and embedded within
everyday ways of relating. The individual narratives
paint a vivid picture of this experience as they were
constructed from the supervision dialogue.
Working with the practitioners through the milieu of
clinical supervision was undoubtedly a powerful way of
working with them towards enabling that person to
realize desirable practice. Perhaps the realities of
implementing new innovation, such as clinical supervi-
sion into practice cannot be expected to bring about
radical change because such innovation is accommo-
dated within an existing culture, rather than actually
change the culture. As the study revealed, the culture was
not accommodating to the development of clinical lead-
ership. As new clinical leadership programmes seem to be
demonstrating, such programmes do need to be
grounded in the practitioners’ everyday experiences
where accommodation issues can be revealed. It is worth
reflecting on words from �Making a Difference� (1999).
Aspiring leaders need to be identified, supported and
developed. Senior colleagues have an obligation to spot
and nurture talent, to encourage and develop leadership
qualities and skills and to create a professional and
organizational climate that enables the next generation
of leaders to challenge orthodoxy, to take risks and to
learn from experience (p. 53).
Supervision fits this bill well although empowering
the leaders to understand and challenge orthodoxy
proved beyond them perhaps because �orthodoxy� was
so embodied within them. As it was, clinical supervision
was often another thing to fit in to busy lives and was,
to some extent, resisted especially as its value was
unproven and unsupported by the organization in any
formal sense.
References
Barker A. & Young C. (1994) Transformational leadership: the
feminist connection in post-modern organisations. Holistic
Nursing Practice 9 (1), 16–25.
Belenky N.F., Clinchy B.M., Goldberger N.R. & Tarule J.M.
(1986) Woman’s Ways of Knowing. Basic Books, New York.
Bond M. & Holland S. (1998) Skills of Clinical Supervision for
Nurses. Open University Press, Buckingham.
Butterfield P.G. (1990) Thinking upstream: nurturing a con-
ceptual understanding of the societal context of health beha-
vior. Advances in Nursing Science 12 (2), 1–8.
Cavanagh S. (1991) The conflict management style of staff nurses
and managers. Journal of Advanced Nursing 16, 1254–12600.
Department of Health (1999) Making a difference. Department of
Health, London.
Dunham J. & Klafehn K. (1990) Transformational leadership and
the nurse executive. Journal of Nursing Administration 20 (4),
28–34.
Fay B. (1987) Critical Social Science. Polity Press, Cambridge.
Foucault M. (1979) Discipline and Punish: the Birth of the Prison.
Sheridan A (Trans) Vintage/Random House, New York.
Freidson E. (1970) Professional Dominance. Aldine Atherton,
Chicago.
French J. & Raven B. (1968) The bases of social power. In Group
Dynamics (D. Cartwright & A. Zander eds), pp. 150–167,
Row Peterson, Evanston, IL.
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, Oxford.
Johns C. (2001) Depending on the intent and emphasis of the
supervisor, clinical supervision can be a different experience.
Journal of Nursing Management 9, 139–145.
Johns C. & Graham J. (1996) Using a reflective model and guided
reflection. Nursing Standard 11 2, 34–8.
Johns C. & Hardy H. (1998) Voice as a metaphor for transfor-
mation through reflection. In Transforming Nursing Through
Reflective Practice (C. Johns & D. Freshwater eds), pp. 51–61.
Blackwell Science, Oxford.
Kemmis S. (1985) Action research and the politics of reflection. In
Reflection: Turning Experience into Learning (D. Boud,
R. Keogh & D. Walker eds), pp. 139–164, Kogan & Page,
London.
Kieffer C. (1984) Citizen empowerment: a developmental per-
spective. Prevention in Human Services 84 (3), 9–36.
Klakovich M. (1994) Connective leadership for the 21st Century:
a historical perspective and future directions. Advances in
Nursing Science 16 (4), 42–54.
Lieberman A. (1989) Staff Development in Culture Building,
Curriculum and Teaching: the Next 50 Years. Teachers’
College Press, New York.
Mezirow J. (1981) A critical theory of adult learning and edu-
cation. Adult Education 32 (1), 3–24.
NHS Management Executive (1993) A Vision for the Future.
Department of Health, London.
Rolfe G., Freshwater D. & Jasper M. (2001) Critical Reflection
for Nursing. Palgrave, Basingstoke.
Rost J.C. (1994) Leadership: a new conception. Holistic Nursing
Practice 9 (1), 1–8.
Schuster J. (1994) Transforming your leadership style. Associa-
tion Management 46, L39–L42.
Senge P. (1990) The Fifth Discipline: the Art and Practice of the
Learning Organisation. Century Business, London.
Smyth W.J. (1987) A Rationale for Teacher’s Critical Pedagogy.
Deakin University Press, Melbourne.
Sofarelli D. & Brown D. (1998) The need for nursing leadership in
uncertain times. Journal of Nursing Management 6, 201–207.
Trofino J. (1995) Transformational leadership in health care.
Nursing Management 26 (8), 42–47.
Vladeck B. (1992) Healthy care leadership in the public interest.
Frontiers of Health Services Management 8 (3), 3–26.
Webb C. (1990) Partners in research. Nursing Times 86 (32),
40–44.
C. Johns
34 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 25–34
