1.0 Background
Core Clinical Supervision is focussed at providing a restorative activity to assist in fostering confidence and enhancing care delivery within primary care settings. Its introduction was in line with the NHS Peoples Plan (2021) and recognises that those people working within healthcare have been and still are working under significant pressure, which will influence their wellbeing and work cultures (NHS England, 2022).
It has been defined as a formal process of professional support which should be viewed as a means of encouraging self-assessment, analytical and reflective skills, and can both enable and support practitioners in clinical practice. Additionally, it has been grounded in the recognition of the importance of ongoing support, professional development, and quality improvement within the healthcare sector.
However, there has been limited evaluation as to its impact on general practice and its embedment within clinical settings since its introduction.
This is due to supervision activity being dependent on competing service demands and is frequently seen as not being a priority. This can be reflective of organisational culture and potentially an absence of managerial support or buy-in, which can be demotivating and damaging to the workforce attainment (Akhigbe et al, 2017). This has proved to only lead to negative consequences around staff wellbeing and poor patient care safety and delivery (Webb et al, 2015).
The Care Quality Commission (CQC) does critically audit supervision activity within the workplace as it is aware that it helps to manage the demands and pressures created by the nature of healthcare delivery. If not protected or supervision is not recorded there is a risk of regulatory action for noncompliance (CQC, 2013).
Fortuitously, the core clinical supervision model has begun to gain momentum and is strongly embedded within some areas of general practice. An evaluation of the barriers and enablers of supervision has been examined (Goode et al, 2024) but this is only regional where funding was made available. Often practitioners working in general practice, state that confidence is key issue in initiating and facilitating supervision sessions following training and that this can be a very dependent variable as to the success of embedding into practice (Gonge and Buus, 2010).
As it takes time to deliver and consolidate training, supervisors do require further coaching and guidance to confidently set up and undertake supervision sessions to peers. Many practitioners have stated more advanced coaching, supervision group mechanisms, and better understanding around learning outcomes for core clinical supervision would be beneficial (Goode et al, 2024).
The study undertaken decided to look closely at general practitioners who had successfully embedded and regularly facilitated core clinical supervision sessions and have an opportunity to share their experiences that may be profitable and insightful for others to learn from. The study also aimed to investigate what elements were needed and what obstructions may impede or arrest its development and embedment. It is hoped the extracted narratives will give faith and impetus to others to keep trying to set up their own supportive sessions and acknowledge these brave ambassadors in leading the way with core clinical supervision and betterment of staff and patients in primary care.
1.1 Main aim and objectives
The main aim was to investigate the key elements that assist in initiating and embed core clinical supervision in practice.
The objectives being to examine what are the qualities required for successful facilitation of core supervision and investigate what are the barriers and enablers, that hinder or help core clinical supervision in practice.
Lastly, how facilitators maintain momentum with their peers to create sustainability with the activity of core clinical supervision.
2.0 Methodology and methods
Hermeneutic phenomenology was used to explore the theoretical underpinning for the study (Ho et al, 2017). This approach was considered appropriate to examine and identify the key themes that influence the successful implementing core clinical supervision in practice.
A purposeful sampling technique was used for the identification and selection of information-rich cases and for the most effective use of a limited resource of trained core supervisors (Patton, 2002). This meant identifying and selecting participants who were knowledgeable and experienced with the phenomenon of implementing core clinical supervision in general practice. Also, in addition to being knowledgeable on core clinical supervision practices, participants would have a richness and depth of experiences to offer and communicate in an expressive, and reflective manner, which is a classic learning feature from the training.
However, in this instance the methods chosen were aimed at maximising efficiency and validity and intended to achieve depth of understanding (Patton, 2002) and place primary emphasis on saturation whereby no new substantive information can be acquired.
2.1 Ethics statement
This study received ethical approval from Coventry University Project Reference Number: P173965
2.2. Recruitment and inclusion criteria
The sample of participants were taken across several primary care networks. The inclusion criteria were that the participants must have completed the core clinical supervision training.
Following ethical approval, the study participant information was e-mailed to several primary care partnerships who were undertaking core clinical supervision within their practice. All were invited to contact the researcher undertaking data collection if interested. This was followed by arranging a mutually convenient meeting for further discussion and to obtain written consent to be interviewed.
Table 1 is representative of the roles of the participants who are facilitators in core clinical supervision activities.
| Roles of Participants in Primary Care Settings | Number of Participants |
|---|---|
| Chief Healthcare Operational Officer | n=1 |
| District Nurse Practice Educator | n=1 |
| General Practice Nurse (GPN) | n=4 |
| Nurse Manager | n=1 |
| Counselling Lead | n=1 |
| List of Open-ended questions posed during Interview of Participants |
|---|
| What is your present role title within General Practice? |
| What interested you to undertake the training around core clinical supervision? |
| Why did you implement core clinical supervision in your practice? |
| What or who helped you to embed it into your general practice? (e.g. a person of influence or experience; a type of supervision activity…any others?) |
| Briefly tell us if there have been any challenges/barriers in implementing core clinical supervision in your practice? |
| What advantages do you think it brings to your organisation/peers/yourself? |
| What quality markers are you tending to use and why? (e.g evaluation and staff wellbeing survey specific to the Core Clinical Supervision Model, staff cohort, record of agreement, documentation of sessions, policy). |
| How do you think we could best future proof the Core Clinical Supervision Model to ensure sustainability? |
| Is there anything else you would like to add about your experiences on this topic? |
|
|
2.3 Consent of participating partnerships and data collection
Consent and participation were voluntary, and one-to-one semi structured interviews were undertaken in an open, non-judgemental setting to generate full understanding (Kallio et al, 2016). Interviews were undertaken either through a digital based communication platform or in person within a secure environment. This ensured that no interruption would occur to divert the participants attention and maintain confidentiality of the discussions content. Written informed consent was gained prior to the interview process and audio was recorded digitally. Recorded transcripts were converted into a written transcript and were analysed and re-analysed to examine and determine any themes. All data was stored in accordance with the ethical approval, maintaining confidentiality and data storage security.
2.4 Interview questions
The interview questions were mapped in accordance with research findings undertaken by Rothwell et al, (2021), Rouse, (2019) and Goode et al, (2024) that examined the enablers and challenges to implementing and embedding supervision practices within healthcare settings. See Figure 2.
2.5 Data analysis
Once the interview data was transcribed verbatim, the participant was allocated a numerical coded to protect the identity of participants and be blinded to the other researchers in the interpretative analysis phase. The texts were read and re-read in their entirety, to allow a phenomenal feel for the data content. Significant phrases or sentence text were drawn out, along with clusters of sentences that gave meaning to the text. One researcher solely undertook the interview process, and two other researchers led the data analysis. This, helped to maintain transparency, reliability, and reduce any bias (Aveyard and Sharp, 2017).
A thematic analysis approach was utilised interpreted for any meaning and description (Roberts et al, 2019).
Additionally, the interviews were examined and analysed for any external influences, by exploring their experiences through their facilitation sessions and how this impacted upon their ability to deliver successful core clinical supervision (Devik et al, 2013).
3.0 Findings
The participants in the study had similar experiences with four key themes that emerged. These are expressed in Figure 3.
3.1 Implementing core clinical supervision sessions.
All the participants had engaged and completed the training offered by an accredited trainer. Most stated they regularly attended the updates that the training facilitator would offer post course. This gave the supervisors the supervision they required to maintain consistency and peer support, as well as national updating on supervision developments.
Two participants commented that they had decided to run their groups with another facilitator to reduce any vocal domination in the group which allowed everyone in the session to have a voice and feel comfortable about participating in the sessions.
‘Really hard to sort of make sure everybody gets a chance to have their say or be able to contribute, I brought in a second facilitator’.
Another felt that bringing in a trainer or facilitator would be of benefit in setting up sessions and facilitating them. They also felt that the sessions would be better attended as it would prevent cancellation out of professional respect. However, there was an expectation that this could be provided free of charge, but no specific person was identified who could do this. It was indicated however that an experienced facilitator would help with dissemination of session structure and guidance.
‘I think it would be good if surgeries could be offered a trainer to come in free of charge for so many sessions to set up the supervision, this will help to pinpoint staff knowing an external person is coming in to prevent it being cancelled. Then after so many free sessions it is handed over and I feel this would set up good patterns for it to continue’.
Another participant unified with other supervisors within their primary care network (PCN) to facilitate knowledge and practice exchange and help awareness of other practices operational styles and management of similar services.
’Practices organise and practise, this has been really helpful to us when considering how we work in our own practice and how we could unify our practices in places. It's a very good way of keeping up to date within practice, also for being aware of any new services available or training’.
Some of the participants suggested bringing case studies into the session as a form of learning and how to enhance care patient care and follow up, particularly if they had been challenging experiences.
‘It's so, so difficult on the frontline, you know when you just see patient after patient, but also an opportunity to share any difficult cases or I think anything they were struggling with. I think case studies are really powerful’.
Utilising case studies does prompt practitioners to consider a scenario from another person's perspective. With working through the presenting experience helps to find solutions, but also consider the limitations in practice, such as resources available, any extenuating circumstances, risk tolerance and assessment, and any potential consequences, as well as the appropriate response to complex situations (Heale and Twycross, 2018).
Protecting timetabling for supervision was a concern and 4-6 week or monthly sessions were thought to be appropriate to maintain momentum and sustainability (NHS England, 2023). Therefore, protective time is essential in maintaining good supervision for staff to gain organisational benefit and gaining executive consent was vital to these practitioners.
‘We have their consent as long as we have our sessions every 8 weeks and avoid busy times of the year. We had a full meeting with all the practice nurses in the PCN who were interested’.
3.2 Leading and organising core clinical supervision.
Nearly all participants commented on how challenging it was to get ‘buy in’ from their respective employer or PCN. This has been identified by Goode et al, (2024) as most trained supervisors have had to put patient service demands before supervision practices. Despite this, two participants successfully gained managerial interest and support by giving a presentation to their respective PCN members, clinical directors and practice managers, highlighting the advantages and benefits of implementing core clinical supervision.
’We approached our PCN (primary care network) by giving a presentation and they thought it would be excellent for all the nursing team across the network to liaise and learn from each other’.
‘We initially undertook the training to provide in-house to our nursing team but we then decided to approach our PCN board to see if all of the practices would be happy for us to role this out PCN wide to the GPNs (general practice nurses) and later the HCAs (health care assistants) and ARRS (additional roles reimbursement scheme staff). The board were extremely supportive as were the GP partners in attendance at the meeting’.
The above comments highlighted that by offering to present the benefits and enablers that not just the staff, but the organisation is likely to be more receptive to its inception and implementation (Noelker et al, 2009; Chiller and Crisp, 2012). Negotiation between organisational parties can be challenging particularly if there is an absence of managerial support and little motivation to perceive the distinct benefits to workforce culture (Wilson et al, 2016). Therefore, it would be wise to be open and candid with regards the potential negative consequences that focus on poor staff wellbeing, retention and patient safety and care delivery, as well as failure to attract high quality staff (Pack, 2016; Nancarrow et al, 2014; and Rothwell et al, 2021).
There was significant indication from many participants that their own development in leadership capability was enhanced by undertaking negotiations and supervision sessions that gave them a better understanding of the multiple and many layered complexities with engaging within general practice.
‘I think it's really helped my leadership skills. I think it's really you know, supervising, doing that sort of supervision. It happened with my facilitation skills’.
3.3 Professional and personal development outcomes
This key theme was predominant throughout most participants commentary. The emphasis was strongly on wellbeing, developing as a person as well as a professional, feeling supported and having a sense of purpose and value within the organisation.
‘I wanted to help support my team and make them feel like they have been given time to develop themselves. I think it will make them feel valued in their role’.
The personal and professional growth of the practitioners saw an increase in their empathetic and congruent capacity, and that core clinical supervision offered them the safe space to be the person and practitioner that matches how they feel and think about their clinical situations. All participants had a sense of harmony and agreeability and felt that supervision offered an opportunity to explore internal and external threats and enablers in a trustworthy peer-led environment (Redpath et al, 2015).
‘I can be a neutral person offering support for them to see the bigger picture of outside influences, which often affects clinical practice’.
Despite the positivity that surrounds core clinical practices, participants highlight that the perception of supervision with some peers and PCN staff is that it is a process of scrutiny and critical assessment (Beddo, 2012).
‘And in a lot of cases staff reported that they only have supervision as like punishment when something could go wrong’.
This is quite challenging for facilitators and supervisors to overturn particularly if staff perceive this as a performance indicator or assessment. This can be exacerbated if management have not fully bought in to supervision practices and see it as a threat to disrupting clinical services and output (Churchill and Rashid, 2017).
Supervisors are strongly advised to emphasize the positive image of core clinical supervision and demonstrate the evidence through their own personal and professional enhancement and by being supportive and pro-active in challenging situations. Equally, demonstrate their learning through better practice and any quality indicators that are used to measure overall staff and patient satisfaction that demonstrates high quality care delivery.
‘Staff feel listened to and supported in challenging clinical situations. Use a process that supports staff in building confidence and improving practice through learning and not punitive measures’.
3.4 Quality Improvement Indicators
All healthcare professions are required to undertake continuous professional development (CPD) throughout their career and be documented each year as part of their revalidation process. All General practices are responsible for making sure that their workforce is competent and up to date and this is in line with their regulatory body (CQC 2023).
Employers are expected to identify the training and development needs of the individual at the start of their employment and then be reviewed regularly.
The Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations set out a provider's responsibilities (legislation.gov.uk 2014). The Care Quality Commission (CQC) cannot prosecute for a breach of this regulation or any of its parts, but can take regulatory action, and may refuse registration if providers cannot satisfy concordance with the regulation of staff development.
Participants were asked if they kept any core clinical supervision records that represented a quality marker to be used as part of their inspection audit.
Participants indicated that they had a form of recording their sessions, but a variety of processes were used from diarised sessions being only recorded to more formal documentation.
‘We log the dates of the meetings in our diaries so that's how to record when they happened’.
‘After each session I complete notes on the meeting and the subjects covered. This is then emailed to each individual along with details of the next meeting’.
To ensure that quality assurance and safeguarding patients in accordance to the general practice policy is being adhered to, having some documentation and / or contractual arrangement with practitioners ensures good governance and that the activity of core clinical supervision has taken place to satisfy CQC regulation and confidentiality.
‘I was very careful to ensure my response made them aware that the attendees set the agenda by items that they bring to discuss. Our policy clearly states that we will not share the content of the sessions unless there is a safeguarding issue, the supervisees sign a contract before they begin to this effect’.
Other comments were broader and spoke of the positive impacts around prevent critical incidents and providing the highest quality of care to patients, through professional development.
‘In my experience, clinical supervision can possibly help prevent clinical incidents, as it supports a more reflective, self-aware practitioner, who is confident within their own scope of practice, and therefore are safer practitioners’.
Lastly, the need to preserve protected time (Rafferty and Holloway, 2022) to highlight any training needs and accommodate discussion on policy changes that could have an impact on care delivery and patient safety.
‘The advantages of providing this were that the patients are receiving the best standard of care, the staff and students within the team feel more supported and we also use this protected time to highlight any training needs and communicate forward plans to all, thus enhancing the team skill set further’.
4.0 Discussion
The findings do highlight some concerns. The term ‘supervision’ is often used alongside performance management, which will influence the interpretation of ‘clinical supervision’ and a willingness to engage with it and this maybe why there is some scepticism to engage in the process. Equally, sustainability is at risk if clinical demands continually increase, and override supervision sessions that will lead to diminished improvement measures.
The participants did express that an external educator supporting core clinical supervision in practices would be strongly advisable and provided a neutral, altruistic approach to minimise any conflict and assist in directing group dynamics. This would influence the organisation creating a better, respectful and inclusive work culture that will see a reduction of incivility particularly when work is stressful. This promotes better understanding and communication between staff members as it is a safe space to express concerns and clarify perceptions (Bar-David, 2018). This supports the findings that better problem solving is often desired to drive quality care.
The evidence does suggest that further training is needed around change management and an understanding of quality improvement metrics. The quality of supervision and recording of sessions was variable and therefore could be unreliable in terms of audit and quality improvement metrics (Harrison et al, 2021).
The positive influences that have had significant change have been the empowerment from multidisciplinary working and the integrated neighbourhood teams in primary care. This provided a better perception and understanding of the complexities of people's roles and the expansion of practice within the PCN. This was indicated with the need for expanding supervision support for the Additional Roles Reimbursement Scheme (ARRS) and Health Care Assistants (HCA) (NHS England, 2023).
The need for a sense of safety and professional value is a common thread throughout the study and it is a key factor that indicates whether staff will remain in their current posts and their respective profession long term. The measurement of attrition and retention is vital to gauge whether offering core supervision is one component to prevent it as well as overall staff satisfaction. Indications are positive and that many practitioners have expressed that it helps them to fulfil the requirements for revalidation, maintain their well-being and attracts high quality staff to the organisation (Foster 2021).
5.0 Limitations
However, a sample size of eight participants was considered appropriate for this phenomenologically study, where the aim is to obtain in-depth and rich data from a small number of participants (Hays et al., 2012). However, there is a risk of lacking generalisability of findings and potential for bias in a purposeful selection of participants and could have an impact known or unknown confounders.
6.0 Recommendations for effective and sustainable core clinical supervision in practice
7.0 Conclusion
As healthcare policies and regulations evolve around health practitioners needs for core clinical supervision it is hoped that such practices will adapt and become embedded. This will lead to a nurturing, happy and high functioning workforce that is not only concordant with the latest regulations and standards in primary care, but increasingly creative and resourceful in facing the ongoing complexities of healthcare delivery in general practice.