PROFESSIONAL ISSUES
Clinical supervision: an important
part of every nurse’s practice
Oladayo Bifarin and David Stonehouse
C
linical supervision should be an important part
of the nurse’s clinical routine, but is one that
realistically is often neglected owing to the pressures
of work.This article aims to raise awareness of this
important practice and to encourage nurses to
embrace clinical supervision, both for themselves and their
professional development, but also, importantly, for their patients
and the quality of the care they deliver.
Definitions
Lyth (2000) defined clinical supervision as:
‘A support mechanism through which
they (mentor/mentee) can share clinical,
organizational, developmental and emotional
experiences with another professional in a
secure, confidential environment in order to
enhance knowledge and skills. This process will
lead to an increased awareness of other concepts
including accountability and reflective practice.’
Lyth, 2000: 728
Arguably, clinical supervision could be mistaken for an
appraisal; however, Livewell Southwest, for example, stipulated
clearly that:
‘In essence it [clinical supervision] can be
described as a professional conversation to
facilitate reflective learning, through a
non-judgmental process, which is separate
from appraisal.’
Livewell Southwest, 2016: 8
Supervision aids accountability, which is necessary for
effective practice, and it ensures delivery of quality care (Zutshi
et al, 2007). Accountability is one of the prominent factors that
has influenced research on supervision (Harris, 1994; Bernard
and Goodyear, 2014). Clinical supervision in nursing requires
an active engagement as well as a reciprocated relationship
Oladayo Bifarin, Mental Health Nursing Student, MSc
Pre-registration Pathway, Faculty of Health and Social Care,
© 2017 MA Healthcare Ltd
Edge Hill University, Ormskirk
David Stonehouse, Senior Lecturer, Faculty of Health and Social
Care, Edge Hill University, Ormskirk, stonehod@edgehill.ac.uk
Accepted for publication: March 2017
British Journal of Nursing, 2017, Vol 26, No 6
ABSTRACT
Clinical supervision involves a supportive relationship between supervisor
and supervisee that facilitates reflective learning and is part of professional
socialisation. Clinical supervision can take many different forms and may
be adapted to suit local circumstances. A working agreement is required
between the parties to the supervision and issues surrounding confidentiality
must be understood. High-quality clinical supervision leads to greater job
satisfaction and less stress. When it is absent or inadequate, however, the
results can be serious and it is particularly important that student nurses are
well supported in this way. Further research in this area is necessary.
Key words: Clinical supervision ■ Accountability ■ Confidentiality ■ Reflective
practice ■ Professional socialisation ■ Staff development ■ Leadership
between the supervisor and supervisee (Udlis, 2008). However,
there appears to be inconsistency and confusion about the
purpose of clinical supervision in nursing (Winstanley, 2000).
Fowler (2013: 786) argued that, despite the existence of clinical
supervision in the domain of nursing in the UK, nursing
practitioners ‘seem to be unaware of either its existence or
its purpose’.
Benefits
Certain benefits have been attributed to high-quality clinical
supervision. These include job satisfaction, increased depth of
knowledge, reduced emotional stress and burnout, and increased
self-awareness. It also enables reflective practice, provides support
and encouragement and develops self-confidence and self-
esteem (Baylis, 2014). The principles of clinical supervision
facilitate the development of nursing leadership, together with
the opportunity to critique clinical and cultural practices within
a safe environment (Blishen, 2016).
Reflective practice
Owing to the nature of nursing, clinical supervision takes place
in a variety of settings. Irrespective of this, it is important to
note that the fundamental principles of clinical supervision
must not be compromised (Nursing and Midwifery Council
(NMC), 2006) (Box 1). It is evident that clinical supervision
has a key role to play in positive professional socialisation and,
in order to achieve this, reflective practice must be encouraged.
Professional socialisation is defined as identifying oneself
within a profession through the acquisition of knowledge and
skills (Becker, 2013). McColgan and Rice (2012) highlighted
331
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Box 1. Clinical supervision principles
■■ Clinical supervision supports practice, enabling registrants to maintain and improve
standards of care
■■ Clinical supervision is a practice-focused professional relationship, involving a
practitioner reflecting on practice guided by a skilled supervisor
■■ Registrants and managers should develop the process of clinical supervision
according to local circumstances. Ground rules should be agreed so that the
supervisor and the registrant approach clinical supervision openly, confidently and
are aware of what is involved
■■ Every registrant should have access to clinical supervision and each supervisor
should supervise a realistic number of practitioners
■■ Preparation for supervisors should be flexible and sensitive to local circumstances.
The principles and relevance of clinical supervision should be included in pre-
registration and post-registration education programmes
■■ Evaluation of clinical supervision is needed to assess how it influences care and
practice standards. Evaluation systems should be determined locally.
Source: Nursing and Midwifery Council, 2006
the relevance of supervision as it enables reflective practice.
Reflective practice has three important elements (McColgan
and Rice, 2012; Fowler, 2013):
■■ Restorative (supportive): enables nurses to raise emotional
concerns and helps them build their confidence
■■ Normative (promoting accountability): enables nurses to
maintain and safeguard effective practice. This helps nurses
to recognise areas of deficiency in their practice
■■ Formative (encouraging learning): aids the development of
knowledge, skills and attributes associated with the nurses’
problem-solving and critical-thinking abilities, using a
reflective model.
The Code
Section 9 of The Code (NMC, 2015) states that nurses must:
‘Share your skills, knowledge and experience for
the benefit of people receiving care and your
colleagues.’
NMC, 2015: 8
Clinical supervision enables skills, knowledge and
experience to be shared among the team. Section 9.1 states
that feedback to colleagues needs to be honest, accurate and
constructive. Section 9.2 states that nurses must:
‘Gather and reflect on feedback from a variety
of sources, using it to improve your practice
and performance.’
NMC, 2015: 8
Section 8.4 states that nurses must:
‘Work with colleagues to evaluate the quality
of your work and that of the team.’
NMC, 2015: 8
Through clinical supervision, nurses and clinical teams
can look back and evaluate care given, then look forward
to identify where improvements can be made. Section 19.1
states that nurses need to:
332
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‘Take measures to reduce, as far as possible, the
likelihood of mistakes, near misses, harm and
the effect of harm if it takes place’.
NMC, 2015: 14
By talking through issues in clinical supervision, potentially
harmful situations and practices can be identified.
Nurses have a duty to undertake lifelong learning. Section
22.3 of The Code states nurses must:
‘Keep your knowledge and skills up to date,
taking part in appropriate and regular learning
and professional development activities that aim
to maintain and develop your competence and
improve your performance.’
NMC, 2015: 17
Clinical supervision is one important way in which
professional development can be achieved.
One-to-one, group or peer supervision
The supervisee should choose what form the clinical supervision
takes and be prepared to say no if they believe a particular type
will not be effective in meeting their needs (Freeman, 2006).
One-to-one, or individual supervision was considered by
Bernard and Goodyear (2014: 131) to be ‘the cornerstone
of professional development’. Lillyman (2007: 3) defined a
supervisor as someone who:
‘May be a peer or someone with experience in
the field of practice that can guide and reflect
on the issues raised by the supervisee.’
Lillyman,2007: 3
Peer-to-peer or co-supervision is where supervisees discuss
their clinical practice with each other. There is no formal
supervisor, with this role being shared among the group (Care
Quality Commission (CQC), 2013).
Group supervision has been defined as ‘three or more people
who come together and interrelate cooperatively’ (Bond and
Holland, 2010: 210). Within group supervision the role of
supervisor is one of a skilled facilitator (Taylor, 2013).The group
can be small or large and may contain professionals from a range
of disciplines as well as grades. In large groups, supervisees will
need to have an awareness of how groups form and develop.
Knowledge of the five stages of group development: forming,
storming, norming, performing and adjourning, as devised by
Tuckman and Jensen (1977) as well as group dynamics and
roles and responsibilities (Belbin, 2010) will be key to successful
group supervision.
The supervisee’s role
The role of the supervisee is threefold (CQC, 2013). First, to
prepare for the clinical supervision session by identifying an issue
that they want to examine. Second, by making the most of the
© 2017 MA Healthcare Ltd
time and then taking any action that comes out of the session.
Finally, the supervisee needs to keep written records, taking an
active role in their own professional and personal development.
Supervisees should be open about the positives and negatives
of their practice, and be ready to share their ideas and thoughts
British Journal of Nursing, 2017, Vol 26, No 6
Use for licensed purposes only. No other uses without permission. All rights reserved.

with their supervisor and other members of the group (Zutshi
et al, 2007).
The supervisor’s role
Van Ooijen (2013) identified the qualities of a good supervisor.
The main qualities are the ability to develop relationships, being
open and ‘not pretending to be more or less experienced or
knowledgeable than you are’ (van Ooijen, 2013: 79). Skills
required are those of questioning, active listening, and the ability
to focus and summarise (van Ooijen, 2013: 81).
The CQC (2013) stated that supervisors should adopt a
facilitative and supportive approach, but when there are concerns
regarding the competence or conduct of a supervisee, they must
act appropriately. They must also keep their own professional
development up to date and have their own supervisor.
Wherever possible the supervisor should not have line
management responsibility for the supervisee.Where this does
occur there is the risk that clinical supervision can become an
appraisal function with the supervisee acting as subordinate,
and the supervisor behaving in a managerial way (Sloan, 2005).
Managers/organisation
Managers need to recognise the valuable contribution that
clinical supervision brings to professional development and
the delivery of quality care. Managers should enable staff to
take time out to attend regular supervision meetings. Both
supervisees and supervisors need to be supported to attend
training to prepare them for their distinct roles.
Zutshi et al (2007) stated that organisations need to have a
‘clear supervision policy, with practice that supports the policy’.
They also stated that senior managers need to lead by example.
There needs to be monitoring of the quality and frequency
of supervision, giving performance objectives to supervisors.
Importance of a contract/working
agreement
Having a contract between supervisor and supervisee makes
the arrangement explicit and avoids ambiguity about the role
of both parties (Freeman, 2006). However, van Ooijen (2013)
disliked the use of the term ‘contract’ in relation to clinical
supervision, preferring the idea of a working agreement. This
implies more flexibility and freedom to change if the process is
not working. van Ooijen (2013) advocated a three-step model
for the development of working agreements: What, How and
What now?:
■■ The ‘What’ stage sets the scene: what is clinical supervision
all about? What expectations do both parties have?
■■ The ‘How’ stage asks: how is this actually going to work?
At this stage the practicalities, such as how often the parties
will meet, are worked out and issues around confidentiality
and accountability are stated and discussed
■■ The ‘What Now?’ stage focuses on goal setting and taking
© 2017 MA Healthcare Ltd
things forward for future practice.
Confidentiality
At the beginning of clinical supervision the subject of
confidentiality needs to be raised. Participants need to know
British Journal of Nursing, 2017, Vol 26, No 6
PROFESSIONAL ISSUES
what they say will remain confidential. However, it must be
understood that there may be times when confidentiality will
not be absolute, such as if unsafe practice has been highlighted,
or a patient is at risk (Peniket and Lillyman, 2007). Power
(2007) went further and stated that if anything is deemed illegal,
breaches codes of conduct, or infringes policies and procedures,
confidentiality may be broken. This needs to be stated at the
outset and may form part of the working agreement.
Discussion and recommendations
In contemporary nursing, nurses work in fast-paced
environments, which can be complex, highly charged and
emotionally driven. It is therefore essential that in-depth clinical
knowledge and skills guide the provision of health care (Ross,
2012). However, concerns continue to arise about the quality
of care provided by nurses in the UK (Roberts and Ion, 2014;
Rolfe and Gardner, 2014).
It appears that newly qualified nurses are leaving the
profession (Cowin and Hengstberger-Sims, 2006; Gaynor et
al, 2006; Health Education England, 2013) and, arguably, this
could be owing to the absence of a sufficient support system.
It is therefore crucial for leaders in nursing to ensure that
the concept of clinical supervision is made known and made
feasible for all nurses.
Emphasis has been placed on the link between lack of
resources and its negative impact on quality of service as indicated
by a survey by Dods Research (2015). However, the absence
of clinical supervision can arguably result in negative patient
outcomes as seen at Mid Staffordshire hospital and described
in the Francis report (Francis, 2013). Clinical supervision could
be a significant tool for staff expected to provide high-quality
care to vulnerable patients.
Having established that clinical supervision is an important
feature in nursing practice, it is important to state that there
are times when it will not be successful. Barriers to successful
clinical supervision may include the personalities of the people
involved, skill mix, staffing levels and nurse caseloads. Clinical
supervision is multifaceted and dynamic and its outcome is
dependent on many factors (Ali and Panther, 2008). However,
Lyth (2000) argued that there is increasing evidence suggesting
that advantages can be achieved when quality clinical supervision
is encouraged.
The quality of the bond established between the supervisor
and supervisee can dictate the outcome of clinical supervision.
It is important to note that, establishing a good quality bond can
be stressful (Watson et al, 2009) and may act as an impediment
to the processes of learning (Watson et al, 2002). It is therefore
imperative to ensure that there is a conducive environment
to facilitate a successful bond, with the aim of encouraging
learning (Kilcullen, 2007).
According to Butterworth et al (2008), there is little
information on the negative impacts/experiences of clinical
supervision. However, Edwards et al (2005) argued that nurses
do not benefit from short and occasional clinical supervision
and highlighted the need for consistent and long-term clinical
supervision.This can potentially help eliminate concerns relating
to nurse supervisees working through reflective practice ‘in a
333
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KEY POINTS
■■ Clinical supervision delivers a range of benefits for both the nurse and for
patient care
■■ Clinical supervision is an important part of nurses' professional
development
■■ Reflective practice is a key part of clinical supervision
■■ The supervisee should be the one who chooses what form the clinical
supervision should take
■■ The absence of clinical supervision can result in negative patient outcomes
mechanical fashion without regard to their own uncertainties,
questions and meaning’ (Boud and Walker 1998:193).
Arguably, genuinely integrating quality clinical supervision
into nursing can potentially help retain competent nurses (CQC,
2013), at a time when there is a shortage of nurses available to
cater for the needs of the ageing UK population.
More quantitative and qualitative research is needed,
measuring moral distress among staff in various settings against
the quality of available clinical supervision.This would have the
potential of fortifying the significant role of clinical supervision
in contemporary nursing. Leaders and managers would then be
able to see clinical supervision from an objective perspective.
Incorporating clinical supervision into nursing practice would
promote refinement in areas such as reflective practice, education
and critical analysis of care provision, quality and person-centred
care (Tomlinson, 2015).
Conclusion
This article has highlighted the importance of the nurse taking
part in clinical supervision. Through developing this practice
and making it a regular part of their professional life, quality
care will continue to be developed and delivered as the nurse
receives support and guidance.  BJN
Declaration of interest: none
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 PROFESSIONAL ISSUES

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CPD reflective questions

■■ Of what benefit do you think clinical supervision is to your practice?
■■ How can clinical supervision be an avenue for your voice to be heard?
■■ What are the barriers to clinical supervision in your place of work and how can you think of some strategies about
how these can be overcome?
■■ Considering the potential benefits of clinical supervision to the nursing profession, how can its fundamental principles
be facilitated among your colleagues and team members?

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