Clinical Supervision – Value and Possibilities.
© Mike Consedine 2004
Work is a fundamental aspect of our lives. It dominates by its sheer centrality. And yet often we pay little serious attention to the work we do, to our suitability for it, to the important relationships that are present in it, or to the way in which our very essence is challenged by it. Further, although we may reflect on what we have achieved, we seldom consider what we have or might become through that achievement.
In mental health or psychiatric nursing such reflections are critical, for it is the person we are that we bring to the therapeutic endeavour. Without reflection and ceaseless striving to resolve inner conflict and to further develop our abilities we are condemned to continue the graceless dance unconsciously mapped out for us by our patients, as they demonstrate over and over the behaviours that keep them chained in the murky existence of mental disorder. We play our part by thoughtlessly enacting those roles which ensure that patient behaviour will not change and that no healing or repair occurs in the psyche which so desperately seeks it. Clinical supervision offers the possibility of bringing about change in this process.
What is Clinical Supervision?
The term ‘clinical supervision’ is somewhat confusing. It is confusing largely because it means different things to different people. In order to understand the complexities of the concept and to reach a suitable understanding of what it might mean in nursing practice, it is necessary to appreciate its genesis and development.
The practice of supervision developed with the early psychotherapists. It is defined by Bernard and Goodyear (1998) as:
“An intervention that is provided by a senior member of a profession to a junior or junior members of that same profession. The relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the junior member(s), monitoring the quality of the professional services offered to the clients he, she or they see(s) and serving as a gatekeeper for those who are entering the profession.”
In this discussion we are referring to graduate nurses who already have a license to practice although the principles are just as valid for any professional relationship. The purpose of ‘serving as a gatekeeper’ is carried out by Nursing Boards or Nursing Councils. The purpose of ‘monitoring the quality of professional services’ is carried out by the line management system of the organization for which the nurse works. That is the task of line management. In nursing therefore clinical supervision is for the purpose of enhancing professional functioning. There are many good descriptions of clinical supervision. Among these the following, dictated to me by Don Fergus c.1988 is perhaps the most useful.
“The function of supervision is to provide and create an environment that permits and provokes the emergence of the supervisee’s spontaneity and creativity that will support them past their impasse so that they can re-enter the client system to do what they have to do with confidence.”
This description contains all the elements that go to make up good clinical supervision as it has been delineated in psychotherapy. The relationship is critical. It is positive, respectful and non judgemental. In a very real sense it may be described as collegial. Within such a relationship the supervisee is willing to conceptualise and explore those aspects of the client relationship which are the focus of this session. Greater consciousness is developed, not only of the client in his/her world but also of those aspects of the self that are engaged in this relationship. Greater understanding brings about a reduction in anxiety which of its nature leads to greater spontaneity. With this comes more possibility for therapeutic intervention.
So the key to good supervision is the relationship just as the key to progress for anyone lies in their relationships. Within this relationship lies the possibility of reflection leading to the emergence of greater understanding, and responses which do not simply recreate and reinforce the client’s misery by re-enacting “previously experienced and usually problematic relationships”(Benfer, 1979). Clearly, reflection which leads to greater understanding requires patience - a willingness to slow down and enter into something, not knowing what will emerge but trusting in the relationship and in the process. Wilfrid Bion (1967) gives this a slightly different slant:
“A key characteristic of the thinking process which clinical supervision aims to facilitate is to develop an increasing capacity to tolerate ‘feelings born of not knowing what to do’ until something more clinically relevant begins to emerge.”
Supervision and Nursing
While it is clear that in psychotherapy supervision the focus must be on the client and on the relationship between client and supervisee, in nursing this is not so clear. Nursing operates in a totally different environment where collegial and authority relationships profoundly affect outcomes for the patient. Nurses are seldom if ever totally responsible for the care of the patient. There are colleagues to whom responsibility is handed over at the end of a shift. There are managers whose responsibilities are wider and whose way of managing may be problematic and there are doctors who are often the final ‘responsible clinician’ and who in their anxiety may be less than sympathetic to dissent. There are also other members of the team who have their own ways of coping with the challenging environment. If the patient is to receive the best care harmonious relationships between all caregivers are important, even vital.
All this means that perhaps clinical supervision in nursing has to address wider issues than those which have been the focus in psychotherapy. Bad feeling between colleagues, difficulty with the authority and competence of managers and negativity toward the perceived arrogance of medical staff have destroyed any possibility of respectful co-operation in many teams. Lack of respectful co-operation in the team will be reflected in the care of the patient. My experience over fifteen years providing supervision and training others is that as much as 70% of supervision sessions have focused on relationships with other staff. Sometimes they start off with a focus on the patient but often development in staff relationships becomes the key to progress in patient care. This leads me to conclude that it is time nurses defined their own boundaries for clinical supervision – boundaries which are suitable for the environment in which they work – rather than simply borrowing from other professions.
Good supervision produces positive outcomes for both the patient and the nurse. For the patient it is likely to produce a relationship which is committed, adequate and in some important sense spontaneous.[i] Such a relationship does not therefore recreate old social atom[ii] behaviours or responses but rather introduces a new response that brings about social atom repair. This will come as a surprise to the patient who has come to expect the old response. The surprise as Lady Bracknell once said is “pleasant or unpleasant as the case may be”. The point is that it will not be a re-enactment of the old and so will introduce new life into the situation. The old and often dysfunctional system in that moment is exploded. With the new intervention the patient’s response, thankfully, is not predictable and the nurse remains ready to deal adequately with this new moment. With this in mind we could say that the true goal of supervision is greater spontaneity in the supervisee.
Supervision often produces other benefits for the patient. When the nurse begins to explore other important relationships in and around the patient’s life she may become conscious of other interventions which would bring about social and personal change. Such interventions may be with family, friends or other health professionals. Supervision provides the opportunity to become conscious of many things by creating a relationship within which the nurse’s “spontaneity and creativity” can emerge as they actively concretise[iii] different relationships and begin to notice through this process something of the complexity of an individual’s life.
For the nurse supervision potentially is a lifesaver. By “life” I am talking about responses which are enlivening and not just a repeat of previously learned and often problematic responses. Disenchantment with the work to the point where our functioning is barely adequate and certainly not enlivening (sometimes called burnout) is caused by the over enactment of certain behaviours or roles. When we have the same response over and over again to situations that we somehow perceive as the same as those we have encountered in the past we will get to the point where the thought of facing another day in that place is more than we can bear. Consider that it is not the place. It is our responses to the place and to the people, the behaviours and the situations we encounter in the place. Supervision offers the opportunity to explore the development of new and more adequate responses to the situations, to colleagues and most importantly to the distressed individuals who are temporarily in our care.
Further the discovery of material that is clinically relevant and yet previously unthought is enlivening. It brings about a certain excitement which banishes anxiety and fills the supervisee with a sense of possibility. Greater liveliness and spontaneity dominate as creative responses emerge fully into the conscious mind. Difficulties drop away as the new life floods through the supervisee. He/she recaptures in this moment the enthusiasm that once informed their work. They are now ready to return to the client with confidence.
Supervision and Development
Supervision primarily aims at the development of the practitioner. This means that the changes which occur through the supervisory process are integrated and therefore become part of the personality structure. Integration of course is a gradual process. It may begin with an insight which leads in that moment of reduced anxiety to a surety about the way forward and some excitement but it yet lacks enactment. Integration is strengthened with the first enactment and further strengthened by subsequent enactments. Whether it is ever complete is a question for philosophy. Certainly with further enactments over time the new response becomes very much a part of who we are as we continue to become who we might be.
Development of its nature is a process of becoming. We build on what is already present. The concept of ‘readiness’, which has lost some ground in the face of the modern determination that all skills can be taught once they are named, is important for true development. You cannot put the roof on a house until the walls are built. If you attempt to do so the emergent structure will be at best shaky. In facilitating the development of interpersonal ability the readiness of the supervisee is of primary importance. The major difficulty is that neither the supervisee nor the supervisor knows in any conscious way just what the supervisee is ready to develop and what the steps are likely to be. Help is at hand. The supervisee brings something to supervision that they want to examine. Within this lies the material through which progress and development can occur. The unconscious, not dominated by the ego has truth in its sight. This hints at the importance of the supervisor’s not leading the supervisee towards a way forward but rather assisting a reflective exploration of the supervisee’s experience. Out of this the way forward will emerge.
For any supervisee the choice of supervisor is critical. The supervisee will seek out a supervisor who will respect them, will not judge them and will relate to them with what Carl Rogers called “unconditional positive regard”[iv] This automatically rules out the supervisee’s line manager. This person is unable to discuss the supervisee’s professional experiences without judgement since the primary task of line management is to monitor standards of practice. There is an immediate conflict of interest, which is likely to result in a somewhat guarded relationship. At some level significant issues of professional practice will not emerge in a relationship where the supervisee may feel rightly or wrongly that he/she will be judged.
A further consideration is that in nursing many issues that turn up in supervision are authority issues. These cannot be effectively worked out in an authority relationship no matter how much good will exists. Hence the supervisee will seek out a supervisor who is not part of the line management system to which they are answerable. Further, the supervisee will seek out a supervisor who can assist with their development and take them forward. This will usually be someone whose development is perhaps a little in advance of their own. A close colleague is a dubious choice since it is likely that the already developed collegial relationship will make the development of a supervisory relationship difficult.
The choice of a supervisor is a very personal one. Some generalizations may prove the rule but these do not exclude exceptions. A good supervisor is likely to be one who works in a different but related area. They will have a solid reputation and credibility. There will be something about them that has immediate appeal either from the way others talk about them or from personal experience. The real test occurs at the first meeting. Questions the prospective supervisee might ask include; do you actively want to work with this person and do they want to work with you? Is there ‘movement towards’ in respect of the work? Is there a sense of mutual respect and an earnest desire on both sides to do the work? This is no trivial encounter. The work of supervision is a work to which both supervisor and supervisee must be committed. It is never easy but when undertaken in a proper spirit it will be enriching for both.
Supervision is a concept that has been in the human race for a long time. Each occupational group that engages with it has claimed and re-defined it. Nurses have yet to agree on its final shape. Yet clearly a fundamental understanding of the nature of human encounter and action steps that emerge from this must provide the foundation for any adequate supervisory arrangements. The ideas set out in the above discussion are the result of experience in the teaching and delivery of supervision to nurses, others in the health professions, and business people. In a world that is dominated by a determination to re enact the past and that demands to know what works, absolutes in any area of interpersonal work are problematic. We can only really indicate possibilities. Outside of that, respect for our own personal experience and a willingness to enter unknowing into this moment seem to offer the best ways forward.
[i] Spontaneity is properly a Morenian concept although it was never defined by Moreno. It was and often is referred to as the “S” factor. Operationally it refers to the ability to bring forth something new in response to an old situation or something adequate in response to a new situation. A spontaneous response therefore is both adequate to the situation and new.
[ii] The term ‘social atom’ refers to the network of significant relationships at any particular point in life. The original social atom then usually refers to the family of origin. Social atom behavior means behaviour which is generated in an earlier social atom and then carried over into the present situation thus in some sense recreating the earlier situation. Sometimes, although the terms do not have exactly the same meaning this is referred to as transference or countertransference.
[iii] Concretisation is a process which converts abstract internal thinking into something more concrete such as a stone or some other object in the room. In recent years I have used playmobile figures to set out situations which have been raised in supervision. For the supervisor there is much to learn about this way of working.
[iv] According to Rogers (1961) p.283 this phrase was coined by Stanley Standal and used in an unpublished Ph.D thesis. Whatever its origin there is a good discussion of it in Rogers (1961) in several different places but particularly on Page 283. More comprehensive discussion of this idea can be found in Rogers (1980)
Benfer, B.A. (1979) ‘Clinical Supervision as a Support System for the
Caregiver’, Perspectives in Psychiatric Care, Vol.17, No 1.
Bernard, J.M. and (1998) ‘Fundamentals of Clinical Supervision’, Allyn & Bacon,
Goodyear, R.G. Boston.
Bion, W.R. (1967) ‘Second Thoughts’, Karnac Books, London.
Fergus, Don, (1988) Personal communication, unpublished.
Moreno, J.L. (1946) ‘Psychodrama, Vol. 1,6th Ed. 1980, Beacon, New York,
Beacon House, Inc.
Rogers, C. R. (1961) ‘On Becoming a Person’ Houghton Mifflin Company,
Rogers, C. R. (1980) ‘A Way of Being’ Houghton Mifflin Company, Boston.
Wilde, O. “The Importance of being Earnest”, this ed. Spring
Books, London 1963.