Clinical supervision: The key to patient safety, quality care and professional resilience. BMC Medical Education
“The performance of the NHS is only as good as the support we give to the staff”
So said the Secretary of State for Health, Jeremy Hunt at a conference at the King’s Fund this week. In doing so he echoed the conclusions of Professor Don Berwick who was asked to review the findings of the Francis report into failures of NHS care in 2013. He concluded, The most powerful foundation for advancing patient safety in the NHS lies much more in its potential to be a learning organisation, than in the top down mechanistic imposition of rules, incentives and regulations.
Missing from these political statements and grand reports are suggestions about how to make the NHS a more supportive, learning organisation. Clinical supervision has been long established as the way that healthcare professionals provide education and support in their working environment and has patient-safety and the quality of patient care as its primary purposes. Whilst clinical supervision is mandatory for trainees, it not routine for those of us who have completed our training and we may spend the majority of our working lives unsupervised. Consequently we become isolated, uncomfortable with having our work scrutinised, and out of the habit of reflecting on our practice with others.
Clinical supervision has many different forms though its functions always include education and support. The flexibility of its forms means that it can be adapted to suit the needs and resources of different groups, small or large, specialist or interdisciplinary. In recent weeks I have attended large group clinical supervision in the form of Schwartz rounds, where senior clinicians presenting have modelled clinical uncertainty, ethical difficulty and emotional engagement with their work that prompted a young nurse to respond, I used to think it was only the most junior members of staff that felt like this.
Narrative-based supervision is particularly suited to the needs of professionals whose challenges have less to do with technical knowledge than relationships with colleagues, administrators, managers, patients and relatives. It facilitates teamwork, open discourse and reflective practices on which a just culture and patient safety depend. It relies on the quality of the questioning rather than expert-knowledge, so that junior staff-members can supervise their seniors, nurses can supervise doctors and hierarchies can be flattened. Its emphasis on identifying and exploring problems reveals medicine’s underlying moral conflicts and helps create habits of ethical thinking on which safe, compassionate care depends.
Professional isolation, stress and burnout are widespread and worsening across many healthcare systems. Regular clinical supervision ensures that health professionals connect with their peers in safe, serious and supportive ways. It has been shown to reduce burnout and compassion fatigue in GPs and improve engagement in hospital doctors and help nurses connect emotionally with their patients.
Stopping us from providing clinical supervision for all professionals are problems of acceptance and access. Some professionals think that they have no need once they have completed their training. They see supervision as a slight on their independence, in spite of the increasingly team-based nature of modern healthcare. Others find that their previous experiences of supervision have not been all that supportive, and prefer other ways of achieving similar goals. Individuals and organisations my not value supervision enough to protect time required for it to take place. Access depends on a culture that embeds supervisory skills throughout the healthcare professions. This is not that difficult. I teach second year medical students to supervise one another using a modified Balint approach. They read aloud a 500 word reflective piece they have written about a patient experience to a small group including myself. The say why this experience mattered to them, any thoughts they had while they were reading it out, and any help they would appreciate from the group. They then sit back and the group discusses the issues raised without directing their comments to the presenting student or making judgements. After a few minutes the presenting student, who has been listening, is invited back into the group to respond. We all take turns to present, including myself, so that the students can see that I am willing to share my own difficulties and am interested in their responses. The depth and quality of their conversation often shows a startling maturity and their ability to help one-another to think seriously about their work comes naturally and improves rapidly. In only a couple of sessions they are able to facilitate themselves.
I hope my paper for this special BMC collection, which brings together theory and evidence in support of clinical supervision, will help create a culture where regular clinical supervision is normal practice for all health professionals. I have little doubt that patient safety, quality care and professional resilience depend on it.