Advanced nursing practice roles are well recognised worldwide as specialist roles in clinical practice. In Ireland, the first advanced nursing practice roles emerged in the late 1990s in an emergency department in a Dublin south inner city hospital. Clinical supervision was embraced as an integral part of this role development in order to sustain professional practice and meet regulatory requirements for the advanced practice nursing role. In Ireland, the education/training role and title of the advanced nurse practitioner (ANP) is governed by legislation. There is a specific division on the register for ANPs. With the recruitment of new ANP candidates on this site, the process was continued and embedded with a more formalised regular group clinical supervision session being conducted on a monthly basis. At the outset, the first Tuesday of every month was chosen as the day for the clinical supervision sessions. Although occasionally the chosen day of the week alters, 25 years on adherence to these monthly sessions remains strong.
This article reflects on the emergence of regular clinical supervision among a cohort of qualified registered ANPs in a busy city centre emergency department. It considers the first steps and the learning curve that evolved over the decades. The initial parameters outlined in the early clinical supervision meetings are described, along with details of how these parameters evolved and expanded over the years, within the dynamic emergency department environment. The many challenging healthcare issues that arose are identified, such as the changing patient demographic, new technological structures, the COVID-19 pandemic, and the changing cohort of ANPs themselves. Recommendations are presented for future clinical supervision sessions for registered ANPs.
Background
Over the past few years, much has been written on the role of clinical supervision in the education and clinical guidance of ANPs (Nursing and Midwifery Board of Ireland (NMBI), 2017; Health Education England, 2017; White, 2017; Fealy et al, 2018, Reynolds and Mortimore, 2021; Lee et al 2023). Presentations to the International Council of Nurses Congress in 2021 identified the key role that regular clinical supervision played during the recent pandemic in guiding, supporting and affirming nurses through critical decision making and unprecedented stressful work environments over many months. For many, however, clinical supervision is seen primarily as an umbrella term that encompasses many facets and approaches to guide in-depth reviews and reflections on nursing practice.
Since the late 1990s clinical supervision has had its supporters and detractors, however it has been positively embraced as a valuable reflective learning tool in the education of student nurses and is widely used as an integral part of mental health nurse training (Edwards et al, 2003; Milne and Martin, 2019, Edgar et al, 2023). In its recommendations for the roll-out of the ANP role, the NMBI (2017) identified clinical supervision as a critical element of professional development by maintaining competence and also providing a valuable support mechanism within the training programme for student ANPs. Indeed, this process seems to have been adopted in many nurse training and education programmes, with positive and negative aspects highlighted. However, it seems that the clinical supervision sessions that are conducted with ANP candidates during their training are not being embraced on a regular basis in clinical practice by qualified registered ANPs (Rothwell et al, 2021). Many qualified nurses highlight issues such as time constraints, staff shortages and a reticence to engage in a potential reveal of knowledge and practice deficits to a group of nursing peers, as factors that pose challenges for clinical supervision roll out on a regular basis (Rothwell et al, 2021).
There are many definitions of what constitutes clinical supervision, emanating from various nursing specialties. Clinical supervision incorporates components of reflective learning and also knowledge sharing. O'Shea et al (2019) described it as a process of regular clinical review of patient treatment and care processes, using protected time to reflect on one's own nursing practices, clinical decisions and shared experiences within the context of a safe and trusted professional group setting in order to maintain professional competency and to meet regulatory requirements.
In a seminal work on clinical supervision, Proctor (2008) highlighted a three-function interactive model incorporating three component processes: formative, restorative and normative practice. Martin et al (2021) identified clinical supervision as a way of relieving stress for nurses and reducing burnout. However, Cook (1996), Yegdich (1999) and Doody et al (2024), stressed the need to include a patient safety focus to avoid the clinical supervision process being used to discuss anything and everything. Lyth (2000), the Centre for Advancing Practice (2020) and Rothwell (2021) all identified clinical supervision as a support mechanism for the sharing of information and clinical knowledge to improve knowledge and nursing practice. In an evaluation study, Bowles and Young (1999) highlighted clinical supervision benefits within the realms of accountability, skill development and support. Bégat and Severinsson (2006) and Doody et al (2024) found attendance at regular clinical supervision sessions increased job satisfaction and wellbeing in the work environment. In her support of the concept of clinical supervision, Kilcullen (2007) challenged the name of the process and asked whether it should be called something else entirely. In their guidance framework, O'Shea et al (2019) stated that ‘clinical supervision is increasingly recommended as a means of supporting professional practice and is fundamental to safeguarding standards, developing professional expertise, and improving the delivery of quality care’.
Organising regular sessions
In an extensive review of the literature on clinical supervision, Rothwell et al (2021) identified several enablers to the process. Significant among these were ensuring protected time for supervision, private space, and flexibility. The logistics of organising the clinical supervision session are not to be underestimated – it requires a designated ANP who is enthusiastic, determined and committed to the task. In the department in question, this role has rotated occasionally but it became clear over the years that commitment and skills vary and the organisation of regular clinical supervision reverts to the individual who has the required skill set. These duties include ensuring the clinical supervision date – the first Tuesday of the month – is logged in the off duty system, sending email or text reminders to all stakeholders, and booking the seminar room, which is situated upstairs over the emergency department. Other tasks around organisation include liaising with and booking an emergency department consultant to attend the session, ensuring that there are no deferred care patient appointments for that morning and ensuring staff on the floor are aware that the ANP clinical service will not be operational for around 2 hours that morning. This is done in a timely fashion to ensure adequate notice for whichever consultant is available on that particular day and to enable as many of the ANPs as possible to engage with the session either in person or remotely.
The decision to have clinical supervision on a prearranged date and time allows for all the necessary organisational adaptation in the clinical area to ensure that the process goes ahead each month. Practically speaking, this means that adjustments can be made regarding cover for the ANPs in the clinical area and guidance advice/review sought from other specialists in the emergency department team while the ANPs are off the floor. It was felt that it was important that all emergency department consultants had an opportunity to attend an ANP clinical supervision session, so they rotate their presence (O'Shea et al, 2019). Documentation of the session itself has changed over the years, with the newer digital record ensuring the removal of all patient identifiers in strict adherence to data protection regulation. Initially, the role of organising the clinical supervision sessions for ANPs appeared cumbersome but after 25 years, it is now practically seamless, with most emergency department staff aware of the monthly process.
The ANPs' clinical supervision usually runs between 08:00 and 11:00. For the most part, the session is completed within the time frame in order to ensure a prompt return to the clinical area and so the staff who are joining on video call or who have come into the hospital just for the session, as part of their continuous professional development (CPD), can return to other commitments. At the end of each clinical supervision session, an informal discussion takes place among all the participants regarding a review of proceedings, ensuring documentation, and identification of any potential improvements. The date and time for next month's clinical supervision session is entered in diaries. It has become clear over time that a failure to do this and enter the date on the ANPs' shift roster can affect the process or reduce the enthusiasm to engage in this. Certain times of the year such as holiday time may warrant moving the session to the following week.
Most, but not all, the ANP clinical supervision sessions have had a designated clinical supervisor. For the most part, this has been one of the consultants in emergency medicine. Snowdon et al (2020) and Rothwell (2021) made the point that using senior medical colleagues for the supervisor role fulfilled many purposes. Primarily the ANP group feel having a senior clinician review the more complex or rarer cases contributes to strengthening team bonds between nursing and medical specialties by sharing knowledge and experiences, but also heightened awareness of the role of the ANP and the many clinical challenges ANPs face in their day-to-day clinical activities. Occasionally the session has been conducted with one of the senior, more experienced ANPs fulfilling this role.
On occasion other members of the multidisciplinary team (eg, occupational therapy or physiotherapy) may sit in for a brief time. Since the social distancing requirements during the COVID-19 pandemic, the facility to join the group remotely is made available. The atmosphere is relaxed and cordial, everyone sits around an oval table.
Format of the sessions
NMBI (2017) advises that each clinical supervision session should incorporate a learning component, a supportive aspect and an accountable component. For the most part, the theoretical framework loosely adhered to is Proctor's Model of Clinical Supervision (Proctor, 2008). This framework is identified as having three components; normative, restorative and formative aspect. The normative element of clinical supervision is related to accountability, professional and organisational standards and the need for competence. The restorative aspect is underpinned by developing strong relationships to support and help people share difficulties, concerns and emotional issues. The formative aspect of clinical supervision relates to developing understanding and skill, through experiential learning and reflection (Proctor, 2008).
The ANPs present a case, it may be complex and unusual or it may be a common presentation that posed a significant challenge for the practitioner. An example case presentation is appended to the online version of this article. The ANP presents the case within the environment of openness, trust and mutual respect. ‘Real listening’ is involved and all participants, including the supervisor, adopt the attitude of mutual respect and professional acceptance by placing themselves in the shoes of the ANP on that particular day. This supportive environment is paramount as clinical supervision is seen as synonymous with a non-judgemental and supportive atmosphere (Cutcliffe and McFeely, 2001; Milne and Martin, 2019; Saab et al, 2021). Several cases may be presented on a given morning or just one or two cases that presented significant challenges. The presenter gives details of the case and highlights any challenges within the pathway of care that evolved for that particular patient.
Reflections on the patient case, based on Gibbs' Reflective Cycle (Gibbs, 1988) (see online appendix), then follows, with relevant research presented and a case discussion opens around the table to the group where viewpoints are expressed, evidence-based knowledge and experiential knowledge unfold and these are shared within the group. This may be in the form of a recent research read on the relevant case or experiential knowledge regarding the challenges of this case. Frequently, more experienced ANPs or the supervisor may share their previous clinical experiences or knowledge with a junior colleague and equally a more junior ANP within the team may highlight a new way of approaching patient care with more up-to-date knowledge on informatics, a recent relevant research paper or technological interventions.
Ethos
The overall ethos of the ANPs' clinical supervision sessions is one of mutual respect and support. Emergency department staff are acutely aware that decision processes in an emergency unit are influenced significantly by the environment and stressors on any given day (Smyth and McCabe, 2017). It is important to state that the initial focus is primarily on individual supervisee narratives as opposed to group action to implement practice change and improvement (Driscoll et al, 2019). Each participant may identify recurrent issues and the ANPs and consultant around the table can all empathise with the presenter as to a specific challenge that may have presented itself in the clinical setting on that given day. The clinical supervision process is not just presenting, reflecting and reviewing specific clinical cases but also being acutely aware of various practice elements within the ANP service.
The literature identifies the need for incorporating evidence-based practice into clinical advanced nursing roles in order to assist in robust decision making and clinical credibility (Gerrish et al, 2012; NMBI, 2017; Kerr and Macaskill, 2020). At the clinical supervision sessions, practices with positive outcomes for patients are reviewed and strengthened, whereas those practices that proved challenging and might have been approached or implemented in a more efficient manner are addressed and alternative approaches to care implemented.
Impact of clinical supervision
Several projects and initiatives have arisen from these sessions (Table 1). During clinical supervision much reflection on practice is conducted within the group and shortcomings in processes and practices are highlighted and discussed. Presenting many specific cases, highlighting challenges and identifying patterns of decision-making, led to audit and research being conducted by the ANPs (Smith and McCabe, 2017; Feeney et al, 2023; Smith et al, 2023; McCabe et al, 2023). Round-table reflections and discussions also led to review of best practice, adaptation and a ‘what could we have done differently?’ or a ‘what can we do better?’ approach to patient care. Many small and sometimes not-so-small initiatives on improvements to patient care and treatment processes were generated from reflections on clinical practice within the small group of ANPs and their supervisor at the clinical supervision meetings.
| ANP observations highlighted at clinical supervision | ANP reflections underpinned by Proctor's (2008) model | ANP change in practice |
|---|---|---|
| Increasing number of patients presenting to the emergency department (ED) with head injury | Normative. We felt there was a need to complete this episode of care without involving other clinicians to request diagnostics. Professional and organisational standards and governance were put in place for ANP referral for brain CT | Introduction of ANP referral rights for brain CT, with subsequent agreement sanctioning referral for facial bones CT |
| Patients presenting with wrist injuries and tenderness in the anatomical snuff box (ASB) who have no obvious fracture on initial X-ray | Normative. It was perceived there was a need for a more succinct pathway for this cohort, in accordance with the evidence and research | ANPs established the ‘Scaphoid Pathway’ where there is a high index of clinical suspicion for scaphoid fracture |
| Pretibial injuries are common and can result in multiple patient attendances. Research indicates creating tension on the skin flap may result in necrosis, infection and prolonged wound healing | Formative. Reflections on the need to keep ANP practices current, incorporating recent clinical evidence on effective treatments and wound management to optimise patient outcomes | ANPs agreed on standardising practice, whereby skin edges for pretibial lacerations should be opposed where possible by hydrating the skin. Sutures and steristrips should be avoided as these create additional pressure and tension on the wound |
| Finger tourniquets fashioned using a latex glove for nail bed repair and finger lacerations can be effective, however, they have been related to associated complications including excess pressure resulting in neurovascular injury and finger ischaemia from a forgotten tourniquet | Restorative. Reflections on near-miss incidents and risk-reduction strategies following a finger tourniquet inadvertently not being removed | ANPs sourced and introduced custom-made digital tourniquets that exert the least amount of pressure to achieve necessary haemostasis |
| Change in patient cohort, increasing number of migrant workers and refugees, social care issues | Formative and restorative. ANP discussion on specific vulnerable patient cohorts and sharing of various clinical experiences of ANPs, and what could be done to highlight and educate ANPs and ED staff on the changing population demographic for the ED | ANPs reached out to community services and organised a representative from An Gardai (police) to give a presentation to all staff on challenges and exploitation of refugees to heighten awareness of staff on these issues and how to address them. Discussion included need to increase awareness and recognise vulnerable patients and support available for asylum seekers in the community |
| Challenges to new staff and a reduction in the number of experienced ED staff on floor | Formative and restorative. Clinical supervision case presentations identified shortfalls in triage or recognising potential high-risk presentations; additionally, failures of simple first aid management | Education sessions to be organised by ED ANPs on monthly basis to assist in education of new and existing ED staff. |
| Challenges in providing modified high arm elevation for patients presenting with upper limb infection/trauma due to lack of ED trollies | Formative. Discussion at clinical supervision on the number of upper limb presentations to ED requiring upper limb elevation. Explored alternative methods of high arm elevation | Successful application made to ‘Design Week’ an initiative in the hospital to work with students from NCAD to develop a design and prototype to support the clinical issue. Successful small grants application to further its development. Now conducting an ED study in the use of the upper limb elevation device (ULED) in ED with interest from plastic surgery colleagues |
| Pain management in ED triage | Formative. Discussion at clinical supervision regarding patients' pain scores and triage and the ED nurses' roles in pain medication administration. An audit of pain management was conducted, highlighting several patients in moderate pain with delays in medication administration | Analgesia medication (paracetamol and ibuprofen) education was initiated by the ED ANP with weekly sessions to ensure training was given to all ED nurses |
| Increasing number of patients who left before completion of treatment (LBCT) after 20:00. The ED national standard says this should be <5% | ED ANP discussion identified patients who LBCT who would have been suitable for the ANP, however they presented to the ED after the ANP service finished for the day | The ‘Deferred Care’ initiative was implemented. Patients presenting to the ED after 19:00 who would be waiting more than 2 hours to be seen could be offered an ANP deferred care appointment the following day. Six slots available Monday–Sunday to provide care for patients suitable for the ANP. Extensive training and education provided to the ED nurses and clerical staff to promote this initiative |
NCAD=National College Art and Design, Dublin; ADON=Assistant Director of Nursing
A suggested framework for sustaining regular clinical supervision is given in Box 1. It has evolved not only from the literature but also the reflections and lived experiences of ANPs involved in this process over many years. It is clear that clinical supervision sessions in the clinical environment can assume many different forms. However, as Lyth (2000) and Gill-Meeley et al (2024) identified, these different understandings and perspectives on clinical supervision should not be a deterrent to its implementation. Martin et al (2014) argued that teaching and shared learning among participants is essential for success in order to avoid failure of the clinical supervision process. The roll-out of specialist roles with increasing autonomy and accountability means that any supportive environment such as that provided by regular clinical supervision in practice must be embraced and encouraged as a positive addition to advanced clinical practice (Reynolds and Mortimore, 2021). Qualified ANPs may have a leadership role in embracing regular clinical supervision in practice and assisting in better implementation of the process for student ANPs in order to optimise clinical supervision sessions within educational structures in undergraduate and postgraduate programmes. Duignan et al (2021) identified the key role that nursing management has to play in supporting such leadership roles in advanced nursing practice. Ultimately, the focus is always on supporting the entire ANP team, both students and registered ANPs, in all aspects of their decision making and clinical practice, thus ensuring optimum care for the patients attending the ANP service.
Sustaining regular clinical supervision
The ability to deliver person-centred care and engage in reflective practice are two key skills expected of nurses. Person-centred care shifts nurses' thinking from the patient's disease state to their personhood. Clinical supervision has been proposed as a place to explore person-centred care. Person-centred practice extends person-centredness to enhance healthful relationships between care providers, services users, and their significant others (Edgar et al, 2023). In an extensive review of more than 800 articles on clinical supervision, Rothwell et al (2021) identified enablers as including ‘regular supervision within protected time, in a private space and delivered flexibly’. Positivity and mutual trust among the participants were also deemed paramount to the process. Saab et al (2021) highlighted significant benefits of a formal clinical supervision process conducted by peer support and review.
Positives and pitfalls
By describing and reflecting on a process of regular clinical supervision among a group of autonomous ANPs working in clinical practice, it is hoped that how the process has withstood the test of time is apparent. Commitment by all to the process is paramount, especially at the outset, and gradually the process becomes integrated into ANP practice. The ANPs who attend regular clinical supervision sessions always say they feel they have missed out on something important if they are unable to attend the session – not just clinical learning but also the support and affirmation of colleagues. It is clear that clinical supervision among ANPs, either with a supervisor or within a peer review process, could be used as a valuable reflective learning and development tool for registered ANPs. Clinical supervision can contribute hugely to supporting and affirming those nurses working at advanced practice level and those who aspire to embrace the role. It incorporates knowledge sharing and can help to change and evolve nursing practices in accordance with patient need.
It should be noted that not all the clinical sessions conducted over the years have followed the exact same format. Initially, with only one or two ANPs, the clinical supervision was somewhat different, a shorter process and more of a one-to-one format. There have been many positive outcomes but also some pitfalls. On some occasions the ANPs themselves and others unintentionally ‘hijack’ the session for lectures, education purposes, department changes, chats, off-duty discussions and debriefing sessions and so on. Some of the initial founding core group of ANPs have moved on or retired but the commitment to continue with regular clinical supervision sessions in advanced nursing practice remains strong and dedicated within the group. The will and determination to remain steadfast to this philosophical clinical paradigm of nursing may indeed be a reflection of all the positive aspects that emanate from clinical supervision in practice.