Effective clinical supervision is an essential component in the development of advanced clinical practitioners (ACPs). When delivered correctly clinical supervision can be, as Milne and Martin (2019) suggested, a social interaction between supervisor and supervisee where both participants can work through shared decision making, using support and encouragement. The multi-professional framework for advanced clinical practice in England (Health Education England (HEE), 2017) refers to the need for regular constructive clinical supervision to be part of the workforce organisational structure, which will help support and facilitate advanced practice to flourish effectively. This is important as clinical supervision is a structured and, most importantly, protected time that enables learning within the clinical environment to take place (Simpson et al, 2017). The Care Quality Commission (CQC) guidance published in 2013 also indicated that clinical supervision is required to meet three key elements, these being professional, clinical and managerial supervision (CQC, 2013).
Clinical and professional supervision are closely interlinked, as clinical supervision offers an occasion for reflection on practice and the identification of skills gaps and learning opportunities, while professional supervision confirms that development and clinical practice are affiliated to codes of professional conduct and continued professional development (CQC, 2013). Essentially, what is important is that clinical supervision offers an opportunity for reflection at the point of, and after, clinical exposure to events and situations, keeping the learning in context and offered in ‘real time’. More recently HEE has produced the Workplace Supervision for Advanced Clinical Practice document (HEE, 2020), which outlines a suggested multi-professional approach to supporting the development of ACPs. The guidance suggests that ACPs originate from an array of professional backgrounds and that each one will have their own needs and requirements during their development journey. This therefore requires not just a single clinical supervisor, but a co-ordinated approach to seeking the right supervision for the individual requirements of the ACP as they progress (HEE, 2020).
At the Royal College of Nursing (RCN) congress in 2019, the RCN discussed clinical supervision, highlighting this activity as valuable in ensuring the provision of high-quality care. The debate supported the suggestion that clinical supervision should be offered by a fellow registered nurse; however, the resolution was not passed (RCN, 2020). This suggestion did not indicate whether this applied to nurses developing towards advanced practice, but when such an advanced level of practice is necessitated, requiring the development of numerous skills, then a multi-professional approach to clinical and theoretical knowledge development must be advantageous.
The impact of clinical supervision
Clinical supervision is clearly an important factor in the development of ACPs. With the advent of the HEE (2020) workplace supervision document, it can only be hoped that its necessity and importance will be recognised and not remain, as White (2017) suggested, invisible, with lip service being paid to its adoption, development and use within clinical practice.
The impact that clinical supervision can have is supported by data taken from a qualitative case study undertaken by one of the authors of this article. The doctoral study explored the impact of a master's curriculum designed to support student advanced nurse practitioners' educational and clinical needs. One of the findings from this study suggested that clinical supervision played an integral part in the students' learning and progression. The following extracts are taken from a small section of the study's interview data. These extracts appear to have a particular focus on clinical supervision and offer the students' voices in response to a question asking for their ideas regarding the development of advanced nurse practitioners and what they felt was important.
‘It is definitely having people interested in you, in the willingness to back you, train you and supervise what you are doing, to then be able to work in an autonomous role … I think that clinical supervision is a big thing … and then obviously the education to back it up … having support and not just support from the university, but from within clinical practice and really from the start when you are offered the job, the support starts.’
The student advanced nurse practitioner speaks of the impact that an engaged and willing supervisor can have on clinical ability and development. There is certainly a need for the academic knowledge to support clinical practice, but progression to autonomy, in the view of this participant, is escalated by someone supervising that expansion of skill.
One theme arising from this qualitative case study was the need for confirmation. The students appeared to require acknowledgement that their practice was correct, that they could offer an accepted clinical reason for their clinical management, that was based on sound and relevant evidence and provided safe and effective care for their patients. This concept was reinforced by the voice of another participant, when they referred to the transfer of theoretical knowledge into clinical practice for the support of their patient.
‘The biggest problem I had was transferring knowledge, that bit of knowledge I had, to the patient, to expand that knowledge, if that makes sense.’
From the interview data it does not appear to be enough to have access to academia or theoretical knowledge without the support for its purpose, and that purpose needs to be placed in context with the help of clinical supervision. However, there are potential barriers to workplace supervision, which include resources, challenges to efficiency via supervision activities that may not involve patient engagement, and personal views that supervision is not pertinent to one's development or not of a high enough standard to be of use (HEE, 2020). Although these barriers exist, the significant impact that clinical supervision can offer to the development of trainee ACPs is, as the participants of this study revealed, of great importance to them. Therefore, the relevance of supporting clinical supervision, which is integral to patient safety and is the responsibility of organisations who provide clinical placements for the development of their workforce (Conference of Postgraduate Medical Deans, 2018).
The experiences shared by the participants in the author's study suggest that progression is enhanced by collaboration and co-working within a clinical environment, during the act of supervision. In the following extract, clinical supervision offers an opportunity to entrench emerging clinical skills and receive feedback and acknowledgment of their accuracy in applying them.
‘I would have liked more clinical supervision, say for example when you're trying to embed those clinical skills … I don't know whether this is a bit old school, a bit “Dick and Dory”, but actually get things signed off.’
Considering the HEE (2020) document on workplace supervision, it is clear that a structured approach, embedded within the employing organisation and delivered by the right supervisor with the right skills, is key. This is reflected in the extract from one of study participants who suggested who should provide and plan the supervision.
‘I think it also depends who your mentor is and who you spend a lot of time working with, who are your senior colleagues … so if you have got someone like my mentor, I discuss an aspect of care with her on a patient and I'm not sure, she'll say, “right then”, and she'll give me advice, but she won't tell me the answer, she says “you need to go and look at this from this point of view” or “next time we have a meeting feedback to me like a CBD [case-based discussion], feedback to me on why that happened”.’
Interestingly, this study also included participants who had acted as medical supervisors. One of the participants' thoughts pertaining to clinical supervision are captured in the extract here.
‘I think it's really important that advanced practitioners during the development phase have the appropriate amount of support and mentoring and de-brief, such that they are developing confidence in clinical skills and the ability to work increasingly independently … it tends to be led by the practitioner and what they need to talk about and what they need to de-brief on … perhaps with lots of supervision initially to allow them to gain the confidence to do that, slowly reducing down.’
Both the medical supervisor and the student advanced nurse practitioners suggested a structure to the supervision process, which is also outlined in the HEE (2020) document. The comment suggesting that the supervision is frequently led by the trainee advanced clinical practitioner links with the proposal by HEE (2020) that each trainee will have different needs, and make progress at a different rate. Therefore, the point identified by HEE (2020) appears applicable: that clinical supervision needs to address the individual requirements and may therefore require different supervisors at different points.
Support for clinical supervisors
One key aspect noted within the study that could certainly challenge effective supervision was time. Although organisational structure, governance and funding are important factors in ensuring effective clinical supervision (HEE, 2020), time was cited as a concern by medical supervisors. One of the medical supervisor participants spoke of the issue of time as follows.
‘Time, time, we don't have enough time together … this is almost done in my spare time, so I don't get given time per se, we sneak together.’
This comment only reinforces the need for clinical supervision to be adequately funded in order to ensure time is afforded to the developing advanced practitioner. Indeed, the medical supervisor referred to financial support as a way forward in securing time with ACPs in order to provide effective clinical supervision.
‘I could invest, for me I have so much to give, I want to tell them so much, I would love to spend time with my trainee … I think the only way is to have a degree of payment really, I don't feel comfortable with that, but actually I can say to the Trust “this is my two hours paid time with my trainee … you can't interfere with that” … that's quite powerful.’
Interestingly, in 2013 the Department of Health introduced substantial financial tariffs for undergraduate medical placements in primary and secondary care. This was mirrored in 2014 for postgraduate medical trainees (Department of Health and Social Care, 2019:4). The reasoning for this was to ensure that medical training provided in primary and secondary care was of good quality, to ensure the trainees developed the knowledge and skills required to meet their clinical competencies. If expectations were not met for the medical students then the funding could be withdrawn, adding an extra leverage to ensure that quality training/education took place. The previous quote from the medical supervisor reinforces the point that in order for trainee ACPs to receive superior supervision and training, adequate funding should be offered to allow this to occur.
Investing in such a structured and supportive encounter can help shape and create a healthier workforce (Milne and Martin, 2019) and is clearly of benefit to the progression of advanced clinical practice. However, Beech et al (2019) indicated that there were vast differences between professional groups when it came to funding, with providers of clinical placements receiving ten times more for medical students than for nurse placements. Although this is related to the funding of placements, it may also explain the experience noted by a student advanced nurse practitioner who participated in the study.
‘I feel like ACPs are not getting much attention when compared to medical students. When the medical students come on the doctors are more, like, interested in them and, like, forgetting the ACPs.’
Extracts from the study's data set from both the student advanced nurse practitioner and medical supervisor participants suggest that clinical supervision underpins growth in confidence and capability. The participants identified the importance of clinical supervision and debrief in influencing the relevance of theoretical understanding and reason and its application into clinical practice, which appeared essential for development and progression.
Conclusion
Clinical supervision is an important factor in supporting the development of advanced clinical practice, but it is not the only factor identified by the study. Advanced clinical practice education and curriculum design needs to be closely interwoven with clinical practice. For this to be effective there must be collaboration between higher education providers and healthcare providers. As indicated, clinical supervision needs to be structured, supported and monitored and clinical supervisors need guidance and development to be able to offer effective support to advanced clinical practitioners, which is identified in the HEE (2020) guidance. Effective clinical supervision is without doubt essential in developing advanced practitioners within clinical practice, offering an opportunity for feedback and debrief with an appropriate clinical supervisor, employing acquired academic knowledge, which in turn supports clinical reasoning and safer clinical practice. With the advent of the HEE (2020) document, which has been developed from the work by Dr Deborah Harding on clinical supervision, we may be a step closer to ensuring effective clinical supervision for ACPs in the workplace.