msk clinical supervision framework 02122014 · nhs gg&c msk physiotherapy clinical supervision...

Clinical Supervision framework

Musculoskeletal Physiotherapy

NHS Greater Glasgow and Clyde

Written by:

Antoinette Reilly

Helen Little

Elizabeth Lightbody

Jane Robertson

Alison Renfrew

Jill French

Written on September 2013

To be reviewed October 2015

NHS GG&C MSK Physiotherapy clinical supervision paperwork: 09122014 2

CONTENTS PAGE

• Foreword and Definitions 2

• Clinical Supervision: Benefits 4 - 5

• Clinical Supervision: Principles 6

• Clinical Supervision : Models 7

• Role of the Supervisor 8

• Role of the Supervisee 9

• Competencies for Supervisors/Supervisees 10

• Clinical Supervison: Documentation 11 - 15

• References 16


Foreword

Clinical supervision is a valuable and important part of the Musculoskeletal

physiotherapy service within NHS Greater Glasgow and Clyde and should be

an integral part of service provision. There is an ongoing commitment by the

organisation to ensure all staff have an equitable and consistent standard of

clinical supervision.

This document aims to define and describe clinical supervision so that there

is a common understanding of its purpose, and how it can support staff in the

delivery of a quality service for patients.

A service wide approach to clinical supervision can contribute towards current

government strategy to provide effective, safe and person centred care (Healthcare

Quality Strategy, Scottish Government 2010). Clinical supervision can also provide a

forum to ensure that staff are valued, listened to and supported which will play a part

in ensuring a positive outlook towards working within NHS Greater Glasgow & Clyde

(FTFT, NHSGG&C, 2013).

Clinical supervision: Definitions

The Department of Health defines clinical supervision as ‘a formal process of

professional support and learning. It is a designated interaction between two or more

practitioners within a safe and supportive environment, enables practitioners to

develop the knowledge and competence to assume responsibility for their own

practice, to enhance patient care and the safety of care provided in complex clinical

situations (DOH 1993).’

The Chartered Society of Physiotherapy defines clinical supervision as: ‘a

collaborative process between two or more practitioners of the same or different

professions. This process should encourage the development of professional skills

and enhances quality of patient care through the implementation of an evidence-

based approach to maintain standards in practice. These standards are maintained

through discussion around specific patient incidents or interventions using elements

of reflection to inform the discussion. CSP (2005).’


The following additional descriptors are used to define clinical supervision

within the MSK physiotherapy service. Clinical supervision;

• should be led by the needs of the supervisee

• should be by virtue of having an experienced practitioner, helping to check that you

are delivering care of the highest standard. This does not need to be a more senior

member of staff

• is confidential, what goes on in the sessions will not (except in very unusual

circumstances) be disclosed to management

• can enable you to identify gaps in your knowledge, explore career pathways and

see the wider team/organisational goals.

Clinical supervision is not;

• a management tool for assessing your performance or directing the way you work

• a formal assessment tool and/or managerial supervision

• a hierarchical or managerial realtionship.

Clinical supervision: Benefits

Benefits to staff

Skills development: You will be able to discuss your work in confidence with

someone who understands the pressures of your job and receive guidance

and feedback about your work. It will enable you to develop your professional

skills and get new ideas and information.

Personal development: It will help you become more aware of yourself and

your effectiveness at work, and explore your personal development needs.

Your supervisor will encourage you to make your own decisions and take

responsibility for them.

Support: Working in health care can be a lonely business. There is rarely

enough time to discuss things with colleagues. This protected time will allow

you time to express and deal with feelings of distress arising from your work.

Professional practice: It will help you examine the work you do and explore

ways in which it could be done better and more efficiently for the good of the

client. It encourages you to look more broadly at what you are doing and why.

Benefits to the Health Board

Valuing staff: By encouraging and supporting supervision an organisation is

demonstrating the value it places on staff. It will help in the recruitment and

retention of high quality staff.


Working culture: Clinical supervision contributes to an organisational culture

that encourages learning, innovation and change. It increases staff

commitment and can be a motivational force.

Safeguarding standards: Clinical supervision can help develop individual

accountability and contribute to the safeguarding and improvement of

standards in clinical practice.

Objectives: Supervision can be a useful way of supporting staff in meeting

personal and strategic objectives.

Risk management: Clinical supervision can be a means by which risk is

identified and reduced. It can provide a check on the standard of clinical

practice, help with critical incident analysis, reduce the number of complaints

and demonstrate the organisation’s commitment to high quality care.

Quality assurance: A commitment to a robust clinical supervision policy can

support the organisation to meet both local and National drivers, such as:

• Clinical Services Fit for the Future

• The National Delivery Plan for the Allied Health Professions in

Scotland, 2012-15

• Healthcare Quality Strategy for NHS Scotland

• Achieving Sustainable Quality in Scotland’s Healthcare: a “20:20”

Vision

Benefits to the patient/client

Direct benefits: the clients/patients will be cared for by more competent and

skilled practitioners.

Indirect benefits: By willingly engaging in clinical supervision both the

supervisor and the supervisee are demonstrating clinical governance in

practice and a commitment to a quality, safe and effective service for all.

Clinical Supervision: Principles

There are many underpinning principles and values for clinical supervision including,

personal and professional lifelong learning, support, commitment, accountability and

responsibility. The following principles will underpin clinical supervision practice

within the MSK physiotherapy service:

1. All professional and clinical support staff will receive clinical supervision.

2. Supervision will be offered on a structured basis.

3. It will be delivered individually or on a group basis.


4. The supervision model will reflect an evidence based model (Proctors 3

function interactive model).

5. Supervision will reflect values based practice.

6. Protected time will be allocated to the session.

7. Supervisees should be able to choose their own supervisor.

8. Each supervisory relationship will have an agreement, record sheet and

reasons for non-attendance.

9. Clinical supervision will be in addition to CPD time, it can enhance and

contribute to CPD activity.

10. Supervision will occur as a minimum 3 times a year. If the supervisee

requires more, this can be negotiated with the supervisor.

11. A supervision session can last for up to an hour, but this can depend on the

needs of the individual.

a. Records of attendance at sessions will be kept by the supervisor/line

manager, to enable audit to be carried out.

b. Records will be kept, by the supervisee, to provide evidence for CPD

and personal development.

c. An annual report will be required from supervisees, outlining changes

in practice and professional development.

12. The venue will be a quiet area, free from distractions and interruptions.

13. The supervisor has the responsibility to treat all information confidentially

unless a concern is raised regarding the supervisee in relation to breaking

the law, endangering patient safety, non adherence to policies or

professional codes of conduct.

14. Either party is free to end the relationship at any time if it is not meeting their

needs. Both parties should review the relationship and the agreement

every year.

Clinical Supervision: Models

Proctor’s (1987) model is one of the most widely recognised models of clinical

supervision amongst health care professions and is probably the most frequently

cited supervision models in the literature.


Proctor’s Three Function Interaction Model of Supervision, (1987).

Restorative - Supportive

Enabling the practitioner to sustain effective work, by supportive help for those

working with stress and distress. This support is achieved by the supervisor

having an unconditional positive regard for the supervisee (this means holding a

continual respect for the individual despite the circumstances). In this supportive

setting, positive challenges to practice can be made.

• Establish good working alliance

• Listen

• Allow supervisee to blow-off steam

• Validate good practice

Help supervisee to: feel safe enough to be honest, reflect on personal reaction

and feelings, and identify possible need for further support.

Normative - Operational

Ensuring the practitioner maintains established standards of care by dealing with

accountability aspects of practice. In the clinical supervision setting this is most

powerfully achieved through reflection on practice in the supportive and

challenging environment provided by the supervision relationship. It is the shared

responsibility of both the supervisor and the supervisee.

• Provide constructive criticism

• Challenge practice when necessary

• Monitor supervisee’s adherence to their ethical code

• Provide supervisee with honest feedback

• Regularly evaluate effectiveness of supervision

Formative - Educational

This is the educational process enabling the practitioner’s development of

expertise and skills. This learning is achieved through guided reflection on

practice in a safe, time protected setting.

• Help supervisee reflect on practice, interactions, and relationships.

• Monitor own reactions to material brought by supervisee.

• Tailor session to supervisee’s level of experience and development


Role of the Supervisor

The Supervisor will:

• Allocate time for supervision sessions.

• Establish a safe environment.

• Explore and clarify thinking.

• Give clear feedback.

• Share information, experience and skills.

• Acknowledge personal and professional blocks.

• Be aware of professional role-issues and boundaries.

• Be aware of organisational policies.

• Be aware of and respect religious, cultural and personal issues.

• Respect confidentiality, unless disclosures conflict the law or professional

code of conduct.

• Keep a record that supervision has taken place.

• The Supervisor will keep such notes as deemed appropriate and share them

with the Supervisee.

• The role of the Supervisor should include the following functions:

o Administrative

o Support/facilitative

o Educative

o Consultative

Within these functions a number of identified responsibilities need to be considered.

Administrative Function • Time

• Place

• Frequency

• Length of Contract

• Duration

Supportive/Facilitative

Function

• Recognising problems/stress of supervisee’s work.

• Exploring personal responses of supervisee, thus

aiming to develop personal awareness


Educative Function • Awareness of different models and methods,

theories and practices

• Knowledge of training options and availability

• Attention to organisation, abilities/methods

• Identify areas for further development of

skills/knowledge

.Consultative function • Exchange and share ideas for new practice e.g.;

new interventions

• Share problems and identify potential solutions

Role of the Supervisee

The supervisee will:

• Initiate and allocate time for supervision sessions.

• Initiate and organise their own personal, professional and practice

development and relevant supervision arrangements.

• Be aware of relevant National, Professional or local codes of conduct and or

practices.

• Be aware of professional role- issues and boundaries.

• Identify practice issues for exploring and improving their practice.

• Explore interventions that are useful.

• Be open to feedback and develop an ability to use this constructively.

• Be accountable for his/her work and informing their manager and Clinical

Supervisor of any difficulties.

• Ensure that they fulfil their supervision contract with their Clinical Supervisor.

• Keep their manager informed of their Clinical Supervision arrangements.

• Keep the paperwork records on the outcome of each session.

Competencies for Supervisor and Supervisee

Both the supervisor and supervisee should ensure that they:

• Understand and can explain the purpose of clinical supervision.

• Understand Proctors formative, restorative and normative functions of clinical

supervision as described within this document.

• Can negotiate an agreement with their supervisor/supervisee.

• Can prepare a structured approach for each session.


• Are clear about the documents required for clinical supervision.

• Can establish a climate within clinical supervision that is effective and sets the

boundaries of confidentiality.

• Can give and receive constructive feedback.

• Can develop an effective supervisory relationship utilising appropriate

interpersonal skills.

• Understands the framework and approach to Clinical Supervision outlined

within this document.

• Scope of practice; when content of discussion is outwith the supervisors

scope of practice this will be discussed with the supervisee and a plan of

action agreed.

For further information please see embedded links:

Make use of supervision - https://tools.skillsforhealth.org.uk/competence/show/html/id/2296/ Provide supervision to other individuals https://tools.skillsforhealth.org.uk/competence/show/html/id/2295/ Support and challenge others on specific aspects of their practice https://tools.skillsforhealth.org.uk/competence/show/html/id/3898/

Useful NHS Education for Scotland training resources

http://www.careerframework.nes.scot.nhs.uk/support-and-supervision.aspx

http://www.flyingstart.scot.nhs.uk/learning-programmes/safe-practice/clinical-

supervision/




Clinical Supervision Documentation

The following documentation is recommended to support

effective clinical supervision.


Name of Supervisor

Name of Supervisee

We have read and agree to our roles as outlined in the NHS GG&C MSK

Physiotherapy Clinical Supervision Framework.

We will meet for: (describe frequency and duration of meetings) for Clinical

Supervision.

We will keep a record of attendance at these meetings and the required minimum

documentation for audit purposes.

We will maintain confidentiality as outlined in the NHS GG&C MSK Physiotherapy

Clinical Supervision Framework and comply with audit requirements.

The supervisee will hold the summary documentation unless otherwise mutually

agreed.

We have also agreed the following; additional points/ground rules (optional):

This is an agreement for:

1:1 Supervision Group Supervision Other

Review date: _______________________________________________________

Signature Date

Supervisee

Supervisor

Supervisee’s Manager

Clinical Supervision agreement (this must be signed by the

supervisor, supervisee and manager and a record kept by the

manager)


Questions to help you reflect on your learning

What did I learn from the experience?

How will I apply this learning in the future?

Will I do anything differently?

Has it changed how I think about my practice?

Have I identified any new learning needs and how am I going to address these?

What might be the benefits of this learning for the client/patient/user/service and

clients?

Supervision Reflection (optional; to be used by the supervisee)


Date of Today’s Session

Name of Supervisor

Name of Supervisee

Name of Observer

(if triadic model being used)

Brief notes on key points it would be useful to record

Please log any Decisions and Actions (say when and by whom)

Signature Date

Supervisee

Supervisor

Supervision Session Summary (to be completed at each

session)

NHS Greater Glasgow and Clyde; Musculoskeletal Physiotherapy Clinical Supervision Documentation

Comments or changes

Date of meeting

Supervision agreement reviewed by both parties

Amendments to supervision agreement

Date of next meeting agreed

Agreed by Supervisor Supervisee

Record of attendance (to be signed by supervisor and supervisee and a copy kept with your line manager)



Clinical Supervision

Useful hints and tips for Clinical Supervisors


1. Preparing to become a supervisor

Starting out; as a supervisor consider asking yourself the following questions:

• What does clinical supervision mean to me?

• What can I offer the supervisee?

• What will help me do it well?

• How will I know it is working?

This will help you understand you own skills and knowledge as a supervisor and

identify any learning needs.

Stages to successful clinical supervision

• Establish and Build a rapport

• Develop a common understanding of the relationship

• Provide a structure to the session, the supervisee is responsible for the

content

• Encourage reflection that leads to change and action that has meaning to the

supervisee.

Learning, action, change and development.

Effective clinical supervision happens when there is high support but also high

challenge.

High Challenge

Low Support High support

Low Challenge

Source: Daloz (1986)

Loss of commitment, stress, little growth, poor effectiveness

Growth through new knowledge, increased empowerment, accountability, effective performance

No motivation to reflect and learn, apathy, poor effectiveness

Fixed in pre-existing model, comfort, unrealistic perceptions, poor effectiveness


2. What to talk about; Content of a session

Proctor’s three function interactive model

Formative Functions

promotes the development of

the supervisee’s skills and

knowledge

Examples;

• Professional

development

• Professional issues

Restorative Functions

recognises the affects of

work, and stresses upon the

supervisee

Examples;

• Time management

• Personal issues which

may impinge on work

• Dealing with stress

Normative Functions

ensures safe working

within frameworks for

practise, professional

and organisational

standards

Examples;

• Work needs and

responsibilities

• Resource / Budget

management

• Other issues

Possible scenarios

A supervisee who says they’re fine and have nothing to discuss. How would you

deal with this?

Consider...

• Encourage them to reflect on something that has gone well.

• What was it that happened?

• What made it a success or a positive experience?

• What did they learn from it?

• What will they do to repeat it?

• How has their practice changed as a result?

• What would have happened if they had done things differently?

Or...

A supervisee has reported they are having difficulty with another member of staff.

Consider...

• How would you support the supervisee to reflect on this?

• What imapct is it having on them?

• What choices are available to them?


• How committed are they to action and change?

Or...

A supervisee is unhappy with changes that have happened recently at work that you

are also unhappy about.

• What are the challenges you face in supporting them?

• How can you support them to identify an action plan that has meaning to

them?

3. Skills

Listening: How to listen effectively

Listening is one of the single most important skills a supervisor can bring to a clinical

supervision session.

Empathic listening, listening to understand from someone else’s perspective.

‘When I ask you to listen and you start giving advice, you have not done what I

have asked. When I ask you to listen to me and you begin to tell me why I

shouldn’t feel that way, you are trampling on my feelings. When I ask you to

listen and you feel you have to do something to solve my problem, you have

failed me, strange as it may seem.

Listen! All that I ask is that you listen; not talk or do, just hear me’.

Ralph Roughton, MD

Taken from the Franklin Covey 7 habits of highly effective people, Habit 5


Questioning; Consider the following types of questions.

Source: Coaching Academy (2008) and Helen and Douglas House Clinical Supervision toolkit

Questions Response Examples Do, Have, Has, Is, Are

Limited or ‘yes’ or ‘no’ answers.

Have you learned anything? Are these the only choices available to you? Is there a barrier in your way?

Who, When What, How Where

Open and encourages supervisee to expand on their thoughts.

What have you learned from this situation? What other choices are available to you? How would you describe the barrier(s) in your way?

Why

May evoke defensive response.

Why did you do that? Can be changed to: What did you aim to achieve when you did that?

Follow the supervisees interest

Supervisee feels valued and works toward own solution.

Tell me more about...

Clarifying

Facilitates understanding.

I think what you are saying is..., is that correct?

Incisive (what if...)

Helps move a supervisee on when they are stuck.

What, if you were performing at your best, would you do?

Check commitment

Assigns supervisee responsibility to take action.

What will you do? When will you do it?

Powerful

Can get to the heart of a problem.

Where will this lead? What is stopping you?

Enquire

Explores values, beliefs or behaviours in situations.

What are you tolerating? What motivates you?

Reframe negative to positive

Moves away from negative self talk or criticism of self or others.

Why is this happening to me? Can be challenged by asking: How can you turn this situation around? How can you make it work to your advantage?

Challenge

Raises supervisee’s awareness.

What are you afraid of? How is this affecting you on a daily basis?


4. Group or Peer Supervision Peer or group supervision is distinct from an in-service training or peer support group. It needs to have an element of challenge and encourage reflection by the participants. To work well there should be:

• Agreed ground rules and a way of working together

• A clear structure and process

• Effective participation from all the group members

• A mechanism to provide feedback

• A facilitator (this ideally would be someone external to the group but can be a group member)

Typically a member of the group would present a challenge or area of development to the group. The facilitator would encourage reflection from the person presenting. They would then invite observations or feedback from the other group members. The presenting group member would then be invited to reflect on their learning and identify actions from the process. It is important at this stage that the facilitator encourages observations and feedback that are non-judgemental and will encourage insight for the presenting group member. Try to avoid providing solutions that have meaning to you and ‘fixing’ instead encourage the presenting group member to find a solution that has meaning to them. Successful peer group supervision requires trust amongst the group and an openess to give and receive feedback without judgement.

For more hints and tips or learning resources see links below;

Support and challenge others on specific aspects of their practice https://tools.skillsforhealth.org.uk/competence/show/html/id/3898/

Useful NHS Education for Scotland training resources

http://www.careerframework.nes.scot.nhs.uk/support-and-supervision.aspx

http://www.flyingstart.scot.nhs.uk/learning-programmes/safe-practice/clinical-

supervision/


References

1. Chartered Society Of Physiotherapy (2005) A Guide to Implementing Clinical

Supervision CSP London

2. DoH (1993) A vision for the future: The Nursing Midwifery and Health Visiting

contribution to Health and Health Care HMSO London

With thanks to the following additonal sources:

• NHS Lanarkshire (2010) Professional/Clinical Supervision Handbook for

Allied Health Professionals, Bedfordshire Clinical Supervision policy

• Birkenhead Clinical Supervision policy

• NHS GG&C Renfrewshire CHP (2009) Clinical Supervision documentation

• South Staffordshire & Shropshire Healthcare NHS Foundation Trust (2011)

Clinical Supervision: Promoting best practice in Health and Social Care

delivery

• NHS Surrey (2011) Clinical Supervision for Health Professions

• NHS GG&C Renfrewshire CHP (2009) Clinical Supervision documentation

• Helen and Douglas House Clinical Supervision toolkit

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