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Does clinical supervision lead to better patient outcomes in mental health nursing?

26 April, 2010 Clinical supervision is claimed to be beneficial, but does the evidence support this assertion? This trial examined the impact on supervisors, supervisees and patients

Edward White, PhD, MSc (SocPol), MSc (SocRes), PGCEA, RMN, DipCPN, RNT, FRCNA, FACMHN, FCN, is conjoint professor, School of Psychiatry, University of New South Wales; Julie Winstanley, PhD, MSc, BSc, CStat, CSc, is associate professor in biostatistics, Melanoma Institute Australia, University of Sydney; both are also directors, Osman Consulting Pty Ltd, Sydney, Australia.

White E, Winstanley J (2010) Does clinical supervision lead to better patient outcomes in mental health nursing? Nursing Times; 106: 16, early online publication. Background It is claimed that clinical supervision contributes to clinical governance of healthcare services, but many claims for its positive effects are unsubstantiated. Aim To test relationships between supervision, quality of nursing care and patient outcomes. Method A randomised controlled trial was conducted across Queensland, Australia, supplemented by qualitative data collection. Results Supervision had sustainable beneficial effects for supervisors and supervisees. The individual performance of clinical supervisors was affected by the culture of the organisation. A positive relationship between supervision, quality of care and patient outcomes could not be established statistically, except in one location. Discussion and conclusion Proposals are made for future supervision implementation and further research is required. Keywords Clinical supervision, Mental health, Patient outcomes

This article has been double blind peer reviewed

Research and development of clinical supervision: main points
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Select a single, discrete clinical location. Agree an explicit, unified, positive position on clinical supervision owned by all levels of management. Carefully identify and prepare supervisors.

. 2010) aimed to inform the evidence base for such claims by testing relationships between clinical supervision. theorise. Retain almost all (>90%) of supervisees over the period of data collection (>1 year). it has underpinned researchers’ interest in establishing the evidence base for causal relationships between supervision. Support supervisors through regular supervision sessions. were early adopters of clinical supervision but. quality of care and patient outcomes (White et al. Deliver sustained. more effective interdisciplinary communication). claims about the benefits remain unproven. Although unsubstatiated in the literature. in the context of an ongoing professional relationship between a supervisee and an experienced practitioner. Literature review Although several models of delivering supervision have been reported (Winstanley and White. length. kudos from exciting and innovative practices). its efficacy has rarely been examined. 1998). 2003). The organisation (reduced absenteeism and staff turnover rates. job satisfaction. effective supervision (indicated by a median supervisee total Manchester Clinical Supervision Scale score of >136). according to standard protocols (size. practically this usually means small groups of some six people attending a prearranged monthly meeting with a trained supervisor for 45-60 minutes. modify and retest. Aim The research study summarised here (White and Winstanley. frequency. International interest in nursing supervision has grown over the last 20 years. Mental health nursing workforces around the world. morale. Supervision provides “time out” and a chance to engage in guided reflection on practice. Background While interest increases in establishing a causal relationship between nursing clinical supervision and better patient outcomes. benefits have been attributed to: • • • Nurses (increased levels of self esteem. quality of nursing care and patient outcomes. especially in Scandinavia and the UK. Patients (improved standards of care. 2006). greater personal and professional development). Allocate no more than nine supervisees to one supervisor. with limited exceptions (Bambling et al. enhanced skills and knowledge.• • • • • • Recruit all staff to participate in supervision. ground rules and so on). Measure. This is designed to develop and enhance future practice.

few large scale evaluations of supervision had been undertaken. Before 2000. Method Sample This trial took place in 17 adult mental health facilities. in public and private inpatient and community settings across Queensland. Dissatisfaction with perceived quality of decision making by managers. the work environment and lack of support. available at www. 2003) reported: • • • • • • • Low overall job satisfaction. Data was collected from July 2007 until January 2009. it was not set up to examine the effect of supervision on the quality of service provision and patient outcomes. Units were randomised to the intervention or control arm of the study.osmanconsulting. The Manchester Clinical Supervision Scale (Winstanley. which raised concerns about standards of supervision and training for nurses. in nine locations.Interest in supervision increased after the Clothier Report (Department of Health. has been used as an outcome measure of the efficacy of supervision in more than 80 evaluation studies in 12 countries and is available in five languages. median age was 46 and they had been qualified for an average of 21 . Its supervision scores range from 36 (worst) to 180 (best). Probably the best known is the Clinical Supervision Evaluation Project (CSEP) (Butterworth et al. Ethical approval was obtained. A review of the literature on reasons for leaving mental health nursing (Edwards and Burnard. Dissatisfaction with lack of in-service training. Supervision was quickly incorporated into the clinical governance of healthcare services in the UK and is increasingly found internationally (Butterworth et al. CSEP provided the test bed for the development of the first internationally validated. Moreover. 1994). Those in the intervention arm implemented clinical supervision while controls did not. Seventeen were female. Dissatisfaction with physical working conditions and burnout. clinical supervision specific research instrument. Lack of staff support. Lack of involvement with the organisation. Supervision training course Across the clinical areas in the intervention group. The median total score to emerge from these international evaluations is 136 and is the threshold above which supervision is thought to become effective. 1998). high levels of emotional exhaustion were associated with direct patient care. 1997) which informed evaluations of assessment tools used to measure the impact of supervision. A fit can be found between the problems that mental health nurses report and the claimed benefits of supervision. Although the study found that supervisees welcomed the opportunity to talk to a trusted colleague (White et al. 2000). 24 nurses were trained as supervisors. Poor job satisfaction. 2008).

Senior managers reported they were optimistic and enthusiastic about supervision. 1988). 1986). 2003). this belief was often confirmed by their experience. but were also disappointed and embarrassed when junior managerial colleagues and other clinical nursing staff did not have a similar conviction when attempts were made to implement it. who visited participating facilities at least once a month for 12 months. They attended an intensive four day course. each of which followed a programme of theory based seminars. during which trainee supervisors set up and delivered group supervision sessions in their respective mental health service locations. patient and unit) and used a range of outcome measures. In the event. All had well established psychometric properties. supervisees (n = 115). sex. no statistically significant differences were found in the control arm by any of the research instruments over time during the 12 months of data collection for nurses.the outcome of supervision. 2009). 2000). patients (n = 88). Data were analysed using SPSS version 16. Each supervisor received their own supervision from one of three area coordinators. patients (n = 82) and non-nursing unit clinical staff (n = 43). Data collection and analysis Qualitative data collection methods were also used to illuminate the quantitative data. led by the research team in July 2007 (White and Winstanley. 1997).years. Psychiatric Care Satisfaction Questionnaire (Barker and Orrell.if not determined . A year long intervention phase followed the end of the course. participants in the intervention arm (n = 9 sites) comprised trainee clinical supervisors (n = 24). Semi structured interviews were conducted with a purposive sample of senior nursing managers and other clinical staff (n = 17) in each participating location. It was well reviewed by trainee supervisors. the Manchester Clinical Supervision Scale (Winstanley. and diary accounts provided on a monthly basis by each trainee clinical supervisor. SF-8 Health Survey (Ware et al. grades) between mental health nurses in the intervention and control arms (n = 186). Service Attachment Questionnaire (Goodwin et al. As anticipated. Maslach Burnout Inventory (Maslach and Jackson. These included: the General Health Questionnaire (Goldberg and Williams. Selected results No statistically significant differences were found in the demographic data (age. they comprised mental health nurses (n = 71). This ranged from . At baseline. The personal disposition of individual middle managers emerged as the main factor which substantially influenced . Findings from the qualitative data at the study’s outset found trainee supervisors were most daunted by the anticipated lack of support from their immediate managers and peers in their clinical areas. 2001). and non-nursing unit clinical staff (n = 11). Quantitative data was collected at three levels (nurse. 1999) and the Perception of Unit Quality (Cronenwett. The course comprised practical sessions with direct feedback. In the control arm (n = 6 sites). for 12 months after completing their course.

the less burnt out they felt. Patients Statistically significant differences in care quality or patient satisfaction could not be shown overall during this trial. or as extra-curricular. between baseline and 12 months. their total MCSS scores did not change significantly. all outcome measures moved significantly in a positive direction and in an intuitively convincing manner. trainee supervisors’ scores revealed an association between high MCSS scores and low MBI burnout. therefore. This finding suggested the following proposition: Significant changes in the formative domain (concerned with developing skills and knowledge and. About a quarter recorded “high” emotional exhaustion levels on the MBI. However. over time. caused by sustained and efficacious supervision. most relevant to impact on patient outcomes) may only become demonstrable after significant changes to the restorative (concerned with personal wellbeing) and normative (concerned with promoting standards and clinical audit issues) domains have become established. nearly 40% recorded “caseness” on the GHQ. over the 12 months of receiving supervision. that is. the better the supervision. to which the best advice for clinical practice development is reported in this article. Supervisors In the intervention arm. Supervisees At baseline. Many factors were found to be present in this setting. In general terms. However. supervisees in the intervention arm revealed normal levels of physical and mental health. There was no significant change in the level of “caseness” for those who scored more than 136. quantitative findings revealed that trainee supervisor total MCSS scores at the end of the course were significantly higher compared with their perception of supervision at baseline. as either integral to local nursing practice arrangements. two MCSS subscales associated with Proctor’s (1986) normative and restorative domains did increase significantly over time. Both the Psychiatric Care Satisfaction Questionnaire and the Perception of Unit Quality instruments revealed statistically significant improvements over 12 months. . Two subscales revealed particularly significant differences over time with regard to trust and rapport and importance/value. It also conveyed how it was conceptualised at local level. in one location (a private sector mental health service). supervisees reported their supervision experience as having met or exceeded their expectations. Significantly more supervisees who scored less than the MCSS median value (136) were found to have moved into GHQ “caseness” over time. as measured by the SF-8. Overall. a quantitative assessment of the likelihood that an individual would be identified as a psychiatric case by a psychiatrist. in a systematic fashion.enthusiastic to unsupportive to hostile and resistant. They also revealed an overall reduction in the level of GHQ “psychiatric caseness”. Control and management of the staffing roster was found to be the mechanism by which supervision was both facilitated and stymied. In six of nine intervention locations. This difference was maintained after 12 months’ experience (Fig 1).

practice. Similarly. whereas usually all that is shown is an absence of evidence of a difference (Altman and Bland. project research officer. care quality and patient outcomes could not be established. 2008) lamented the “tired” discussions in the literature that “offered no new insights”. such was their optimism about supervision that some were not willing to participate unless this was so. is not evidence of absence. may have been mediated by the organisational culture in which they were expected to be at the vanguard of a nursing practice innovation. Moreover. only small changes were seen in either direction. At baseline. no systematic differences could be found in the Service Attachment Questionnaire scores for both groups across three time points. management and policy decision making in the future. This term wrongly implies that a study has shown there is no difference. • This is an edited version of the research published in the Journal of Research in Nursing (White and Winstanley. Brisbane. patients’ (n=159) median score on the Psychiatric Care Satisfaction Questionnaire suggested they were reasonably satisfied with the level of care and service provided. a positive relationship between supervision. The absence of evidence. Conclusion The insights reported here may help in conceptualising and setting up clinical supervision research. Across intervention and control arm settings and over time. was significant. except in one location.Discussion Many senior officers who managed mental health nursing services involved in this trial expressed a preference for their clinical settings to be allocated to the intervention rather than the control arm. The individual performance of supervisors. a literature review on clinical supervision (Butterworth et al. . but was “encouraged that new ideas related to patient outcome and professional development are emerging” and cited this trial as an example. for the substantial grant which afforded this study. as judged by the reported experience of supervisees (and vice versa). Indeed. 1995). from a descriptive point of view. in some settings. Therefore. In addition to these preferences. Randomised controlled trials that do not show a significant difference are often called “negative”. however. 2010) Acknowledgement The authors are grateful to the Queensland Treasury/Golden Casket Foundation. education. Findings reported here support the premise that the training and subsequent participation had beneficial effects for supervisors. not only in terms of ensuring a balance between intervention and control arm numbers. Special thanks are due to Natalie Stuart. These features challenged the trial’s methodological requirements. but also in limiting the scope of appropriate analyses that could be carried out on the data. however. the attrition of respondents subsequently varied by location and. Australia.

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