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Journal compilation 2008 Blackwell Publishing Ltd. Learning in Health and Social Care , 7, 3, 168177

Original article

BlackwellPublishingLtd

Clinical supervision: a means of promotingreciprocity between practitioners and

academicsAnnie Pettifer

Bsc

(Hons)

MSc

PGCEA

RGN

1*

&

Lynn

Clouder

BSc

(Hons)

MA

PhD

MCSP

2

1

Senior lecturer, Coventry University, Priory Street, Coventry CV1 5FB, UK

2

Director of the Centre for Interprofessional e-Learning and Research Fellow, Coventry Univers ity, Priory Street, Coventry CV1

5FB, UK

Keywords

clinical supervision,

focus groups, mutual

reciprocity, professional

identity, reflective

practice

*Corresponding author. Tel.:

+02476 795918; e-mail:

[email protected]

Abstract

This paper explores the potential of adopting an alternative approach to the facilitation

of clinical supervision in a practice context by focusing on the experiences of academic

staff of facilitating clinical supervision for clinical colleagues. The exploratory study,

which forms the basis for ideas generated, was very small and hence it might be better

conceptualized as an analysis of conversations about practice understandings rather

than researchper se

, and certainly, we make no claims of any possibility of

generalizability. Nonetheless, we anticipate that our findings will be of interest to a

wide audience involved in clinical supervision given that the supervision by academic

staff of colleagues in practice is an unusual and unconventional departure from the norm.

The experiences of six academic staff from one higher education institution who

were brought together to form a focus group provide the basis for discussion. Analysis

of the structured discussion led to emergence of four major themes which are

presented in an order that moves from the individuals experiences and perceptions of

themselves in the process, to explore the relational nature of clinical supervision. The

first theme highlights issues of professional identity or academics sense of themselves

as health professionals and/or academics. This leads to the second theme that explores

the tangible benefits identified by participants of providing clinical supervision as

academics. The third theme about the perceived contribution that academics make tosupervision, links, finally, to the perceived reciprocity that springs from clinical

supervision relationships between academics providing supervision in practice, and

clinicians. Our findings, based on this modest inquiry, suggest that this model of

clinical supervision has potential to prove highly fruitful for both academic staff and

their clinical colleagues.

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Clinical supervision by academic staff 169

2008 The Authors

Journal compilation 2008 Blackwell Publishing Ltd.

Introduction

Clinical supervision is a common mechanism

adopted in health and social care contexts to guide

reflection with the purpose of advancing practice(Driscoll 2007). In fact, Johns (1995) refers to the

symbiotic nature of the relationship between clinical

supervision and reflective practice. By creating

opportunity for dialogue, through which practice is

scrutinized and assumptions questioned, clinical

supervision enables critical practice and development

of personal knowledge, professional expertise and

competence. That the dialogue might benefit from

facilitation by an academic colleague, slightly more

distanced from practice than fellow clinicians,

serves as a point of departure for this paper.

Clinical supervision and its facilitation

The concept of clinical supervision is well

established in professions such as nursing, social

work, clinical psychology and occupational therapy,

while for others, such as physiotherapy, it is relatively

new (Sellars 2004). Not surprisingly, interpretations

across professions are diverse with a lack of

consistency in implementation (Gray 2001), due in

part to conceptual ambiguity (Radcliffe 2000) and

the emergence of different structural and theoreticalmodels. However, in some respects this is beneficial

as there is acceptance that no single model can meet

the needs of practitioners in all professional contexts

(Hawkins & Shohet 2000). Nevertheless, a

fundamental common denominator is that clinical

supervision involves exchange between professionals

to enable the development of professional skills

(Butterworth 1998, p. 12). It also seems to be

accepted wisdom that clinical supervision can serve

a regulatory function, provide support and hold

developmental potential, as the following definition

suggests:

[...] a formal process of professional support and learning

which enables individual practitioners to develop

knowledge and competence, assume responsibility for

their own practice and enhance consumer protection and

the safety of care in complex situations. It is central to the

process of learning and to the expansion of the scope of

practice and should be seen as a means of encouraging

self assessment and analytic and reflective skills. (NHS

Management Executive 1993, p. 15).

The potential roles of clinical supervision are

captured in Proctors (1987) framework of

normative, formative and restorative functions

(see Table 1).

This model is valued for its flexibility in that it

illustrates responsiveness to changes in need (But-

terworth et

al

. 1997) and the potential educative,

managerial and supportive functions that are quite

distinct despite the tendency of the National Health

Service Management Executive definition to coalesce

them into one, which to us is impractical. Despite

widespread analysis of the concept of clinical super-

vision across the health and social care literature,

few empirical studies exist. One-to-one supervisionis the most frequently cited structural model

adopted within nursing (Butterworth et

al

. 1997),

although group and multi-disciplinary supervision

is well used across other health professions (Hawkins

& Shohet 2000). There is a substantial literature

addressing the skills and attributes of clinical

supervisors. Skilled supervisors (United Kingdom

Central Council for Nursing, Midwifery & Health

Visiting 1996) seem to be central to a successful

supervisory relationship. Sellars (2004) stresses the

importance of adapting how supervision is facili-

tated to suit the needs of practitioners: experienced

staff probably benefit from a facilitative approach

that encourages them to question their own practice.

However, Sellarss (2004) findings suggest that

supervision by a more experienced supervisor or an

expert in a particular field might also be valued by

less-experienced staff who benefit from a more

authoritative approach. The risk that the supervisor

Table 1 Proctors (1987) three function interactive model

Function Area of focus

Normative Managerial issues and maintenance of

professional standards

Formative Development of skills, ability and

understanding

Restorative Attention to creating a feeling of

understanding and being valued

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might simply provide solutions to problems must be

acknowledged and in agreement with previous

research, she suggests that asking the right questions

is of greatest importance, implying the need for

different skills as practitioners become moreexperienced. Finding such skills might mean involv-

ing someone from a different profession who is not

necessarily a clinical expert (Cutcliffe 2000). Launer

(2006) highlights the need for a relationship within

which affirmation is balanced with challenge, while

Johns stresses the need for respect for the autonomy

of the practitioner and the fostering of an enabling

relationship through which they might envisage the

possibilities of new insights into future practice

(Johns 1995, p. 28).

A perspective from the academy

It might be argued that health and social care

academic staff are in an ideal position to facilitate

clinical supervision in practice; yet, despite searching,

we are not aware of any evidence of previous research

in this area. Academic staff from professional

backgrounds who move into teaching in higher

education, generally maintain their professional

connections if not their practice and perhaps

importantly may possess the questioning skills,

which promote critical reflection. The likelihoodthat educative and supportive functions will take

precedence over managerial concerns might be an

important motivational factor for some practitioners.

However, academic staff are also sufficiently

distanced from practice to question issues that tend

to be taken-for-granted and therefore may

introduce and/or maintain a level of detachment

necessary for impartial dialogue around some

managerial concerns.

Despite working in differing organizational con-

texts and the discourse of division between theory

and practice in the health and social care professions

(Gallagher 2004), practitioners and academic

staff share common roots that convey a sense of

professional identity, as well as a fundamental

understanding of the challenges of practice. Most

academic staff work hard to preserve links with their

discipline, while identities are simultaneously being

shaped within an academic community by the social

processes that occur within that community (Clouder

& Davies 2006). The notion of connection to an

earlier (professional) self reflects findings of research

on stability and change in identity. This suggests

that notwithstanding a contemporary orientationemphasizing change rather than stability, aspects of

being remain the same, providing a sense of continu-

ity over time (Breakwell 1986). Enduring professional

identity also conveys a sense of membership

(Crossley 1996), which could be deemed to be stabi-

lizing (Clouder 2001). As such, academics embody

the notion of plural identities captured in the sug-

gestion that:

A person may not always be one person, nor the same

person from moment to moment, the individual is always

seen as encountering their world in the mode of

personhood, and these personhoods together are seen

as forming a meaningful whole (Rowan & Cooper 1999,

pp. 23).

The perception that individuals are a dynamic

portfolio of selves (Rappoport, Baumgardner &

Boone 1999, p. 99) suggests that identification with

aspects of identity and their assimilation into

professional roles require continual negotiation and

renegotiation. The resultant flux for academic staff

from health and social care backgrounds presents

them with a major challenge, which logically suggests

three possible outcomes:

becoming increasingly divorced from practice;

opting to return to practice; and

trying to maintain their interests across both

fields.

Clinical supervision of colleagues in practice

potentially provides a means of connection to facil-

itate the final option.

Exploring understandings of practice

experience

The aim of this study focusing on understandings

of practice experience was to explore and to begin

to open up a conversation illuminating the value

for academics and their clinical colleagues of this

less conventional model of clinical supervision;

supervision of practitioners by academic staff. It is

important because there is a rising demand for

skilled clinical supervision within health and social

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care (Driscoll 2007). The objectives for this small-scale

study were to consider:

the motivation of academics to provide clinical

supervision;

the nature of the supervision provided; the nature of supervisory links to practice;

the possible benefits of providing clinical super-

vision to teaching, professional development and

scholarly activity;

potential barriers constraining clinical super-

visory activity by academics;

academics perceptions of their contribution to

clinical practice through the medium of clinical

supervision; and

any other issues which academic clinical supervisors

considered to be pertinent to their practice.

Methodology and methods

Despite an extensive literature on clinical supervision,

albeit mainly descriptive rather than research based

(Sloan & Watson 2001; Clouder & Sellars 2004;

Bedworth & Daniels 2007), there is no evidence of

research focusing on clinical supervision in practice,

facilitated by academic staff. This stimulated the

curiosity of some members of a special interest

group with a shared interest in clinical supervision

in one university, who were aware of anecdotalevidence of the success of academic-facilitated

supervision. Given both the unexplored nature of

this area and the wish to capture a range of

perspectives, an inductive approach was adopted in

preference to a more positivistic deductive approach.

This stance necessitated a qualitative design and a

preference for a strategy that suited the topic of the

study in that it reflected its discursive and socially

constructed nature. Focus groups provide a setting

for developing evaluations in interaction, in

conversation with others, in arguments, embedded

in suggestions (Puchta & Potter 2004, p. 22).

Consequently, we opted to run a focus-group

interview rather than conducting individual

interviews on the basis that we felt it might generate

ideas and draw out opinions and perceptions to a

greater extent, allowing in-depth exploration and

yielding rich data (Bowling 2002). Puchta & Potter

(2004) suggest that this approach must be based on

acceptance that attitudes are not preformed but

rather performed. Because ideas generated through

this discursive approach are produced by mutual

understanding rather than external objectification

(Bowling 2002), focus groups are particularlyrelevant when exploring and generating theory in a

highly subjective and poorly understood field.

Given the particularity of the study and its small

sample size, owing to relatively few academics being

involved in clinical supervision, no attempt is made

to claim generalizability of our findings to academics

in other contexts. Instead, we aim for transparency

in illustrating ideas through the use of direct quota-

tions so the reader may judge the trustworthiness of

interpretations and their transferability to other

contexts. Our contribution should be weighed in

terms of its usefulness in advancing pedagogical

understanding and practice functions rather than as

verifiable evidence of wider trends, which it clearly

is not.

Ethical approval was sought and granted by the

University Ethics Committee. A volunteer conven-

ience sample of participants were canvassed through

the circulation of an e-mail inviting staff working

within the Faculty of Health and Life Sciences who

fit the inclusion criteria to take part in the focus

group. Inclusion criteria comprised:

part-time or full-time academic staff possessinga professional registerable health or social care

qualification;

experience of offering clinical supervision to one or

more individuals or groups of clinical practitioners;

joint post holders providing clinical supervision

as part of the practice component of their role; and

willingness and ability to take part in the research.

Staff who expressed an interest in being involved

were sent a participant information sheet and consent

form to complete and return before the focus group.

Six participants were recruited in this way. Their

professional backgrounds were in clinical psychology,

occupational therapy, adult nursing, mental health

nursing and physiotherapy. Two were in split posts

between higher education and practice and all were

female. As we had expected, the sample was diverse,

given that clinical supervision is not a mainstream

activity for academic staff. Therefore, we thought it

important that the focus group facilitated discussion

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of differing conceptualizations of clinical supervision

and participants experience of its implementation.

Clearly, clinical supervision was not the same

across these different professions and contexts

spanning a wide variety of health and social caresettings and the prison service. However, there was

consensus about its fundamental philosophy and

aims. This consensus appeared to offer a foundation

for shared understanding of the experience of facil-

itating the process. Moreover, and possibly as

important, all participants shared the common

experience of working in academia.

The focus group was structured by a semistructured

interview schedule which is set out in Box 1 below.

The discussion was facilitated by a moderator

who maintained the focus and probed to enhance

the depth of the discussion. A second facilitator made

notes of emerging themes on a flip chart, which

was visible to the participants. These themes were

checked for authenticity with the participants in the

concluding stages of the discussion. At the start of

the focus group, participants were asked to intro-

duce themselves to the group, sharing some basic

information about the type of clinical supervision in

which they were or had been involved. Subsequent

discussion was loosely structured around the pre-

determined questions, which promoted discussion

of issues and ideas and the articulation of opinions

previously unconsidered. The discussion was audio

recorded and the recording was transcribed. Parti-

cipants were each sent a copy of the transcript for

member checking and to capture any thoughts thatmight have occurred subsequent to the focus group.

Flipcharts recording major themes agreed during

the focus group were filed ready to be consulted after

analysis of the transcript. The two investigators

analysed the transcript independently by open

coding to produce categories before considering

relationships between categories and establishing

broad themes, before sharing interpretations.

Emergent themes were then compared to the themes

recorded on the flipchart for similarities and differ-

ences as a means of establishing closeness of fit and

veracity of interpretation.

Findings

Four major themes emerged from the analysis.

They are presented in an order that moves from

the individuals experiences and perceptions of

themselves in the process, to explore the relational

nature of clinical supervision.

Professional identity

During the course of the focus group, several

participants expressed their enduring identification

with their professional roots. For instance, one

stated, Im a mental health nurse my background

a long time ago. She went on to explain,

I dont actually see myself as an academic going out [into

practice to supervise]. I see myself more as a therapist

when I go out and not with the academic head.

This participant illustrates the profound impact

of becoming a health and social care professional

that means that the expertise it confers is always part

of a personal and professional identity, providing

a sense of continuity (Breakwell 1986). She also

acknowledges how her identity is comprised of a

number of different selves, which she perceived

enabled her to

leave the academic bit behind when

required, supporting the notion of a dynamic

portfolio (Rappoport et

al

. 1999, p. 99) of selves.

Box 1 Focus group interview questions

Participants will be asked to discuss the following

open questions:

How and when did you decide to offer clinical

supervision?

What motivated you to offer clinical supervision and

what motivates you to continue?

Does it impact your academic work, and if so, how?

How does it affect you professionally, and if so, how?

What do you bring to your supervision that is derivedfrom your experience of being an academic?

How might your supervision benefit practice?

What constrains you as a supervisor?

What are the managerial arrangements with the

organizations in which you supervise?

Is there anything else you would like to add to the

discussion about clinical supervision offered by

academics?

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Conceptualizing selves slightly differently, in

terms of skills that she sees as integral to her profes-

sional identity, another participant argued,

Im not an academic. I dont see myself with that title. Im

an OT. Some other skills that I happen to have to be a

clinical supervisor, some of them happen to be teaching

and its part and parcel of me as an OT.

Individual conceptions of how academic staff

perceive their own identities has potential to have a

profound influence on how they maintain their

connections with their professional roots. It is

feasible that it also influences the way in which they

engage with their role as clinical supervisors. These

two participants seem to indicate that their ease of

stepping into practice to facilitate supervision might

be connected to their strong and unremitting

identification with their service backgrounds and

continuing sense of membership (Crossley 1996)

that is important to them in terms of ensuring

stability. It is possible that for some academic staff,

clinical supervision of colleagues in practice

provides a vital link, that helps to sustain aspects of

professional identity that otherwise might wither

and be overshadowed by other selves.

Tangible benefits of supervision for academics

Perhaps the strongest theme to emerge from the

focus group was that clinical supervision certainly

did fulfil certain needs in the academics present

from the point of view of making them better

academics. Most of the focus group participants

were engaged in the supervision of colleagues in

practice before moving into academia and had

simply continued to fulfil this role:

I was supervising teams of mental health nurses, and then

moved into the academic setting and just continued.

This might seem a little unusual given the

commitments involved in changing cultures and

the initial pressures associated with becoming

accustomed to academic life. However, from a

practical point, one participant suggested, it was

easy to continue because in my diary I have

flexibility ... I had more control of my time and

could swap things easily. Another participant

related how she had dropped her clinical

supervision, and following subsequent reflection

found I missed it, therefore had resumed her

involvement. Both of these participants suggest an

inherent motivation to want to continue in asupervisory role because they feel they benefit from

the relationship. Participants felt that being a

clinical supervisor had an overwhelmingly positive

impact on their academic work. The group agreed

that the most powerful motivation was inspired by

a perceived need to keep in touch with practice,

particularly in the light of a rapid rate of change

within the National Health Service. One participant

felt that by supervising diverse groups, she also had

a sense of the political change as well. Being aware

of the realities of what is going on in practice was

considered important. However, more tangible

benefits of keeping in touch with practice were

evident in the influence on participants teaching.

Supervision not only stimulated thought and new

ideas, it generated contemporary exemplars to be

shared with students so that teaching was constantly

refreshed and updated. One participant spoke

enthusiastically:

I could share stories that I get that are happening now,

this week rather than when I was back in practice.

Another participant suggested:

It makes your job as an academic a bit easier, because you

are having this up-to-date information dripped in over

time, slowly a small amount at a time.

Perhaps most significantly being able to draw on

knowledge from clinical supervision experiences

appears to instil a sense of confidence and authority

to teach among the participants:

It gives you currency, because its very hard to stand in

front of students; well, I find it hard to stand in front of

students when Im not actually having [practical

experience] ... and be genuine when Im not actually [in

practice].

Another participant suggested, it keeps you

thinking about things. Its a good feeling. These

comments suggest a perceived need to steep teaching

in the realities of practice and the importance of

authenticity of knowledge, which lends legitimacy

to the academic conveying that knowledge.

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of the latter is in some ways more valuable than their

own and valuing highly the opportunity to retain

links with practice through vicarious means.

Conversely, academics also perceive that they

tend to

be held in high regard for their academic skills bytheir practice colleagues. It seems that practitioners

and academics recognize a need to feed from one

another to be whole and that there are strong

arguments for promoting clinical supervision as a

means of promoting this symbiotic relationship.

Discussion

Stepping from practice and into the academy is a

challenging and yet potentially transformative

move for health and social care professionals.

However, the difficulties that they then face in

retaining appropriate clinical links and expertise

are often considerable and at times, prohibitive

(Ahern 1999). The importance of upholding

professional identities for staff who work in the

academy is clearly considerable, especially since as

participants in this study suggest it is relatively easy

to get out of touch.

Maintaining connections with practice through

being involved in facilitating clinical supervision has

tangible benefits for academic staff in terms of

enriching their teaching, which in turn bestows asense of credibility. Our findings take this a step

further by suggesting that the effects are potentially

more profound in that facilitating clinical supervision

assures continued identification with professional

values, beliefs and practices as professional demands

and the demands of practice change. That academics

experience contemporary practice through vicarious

means seems not to matter. Continued assimilation

and integration into their profession is at least partially

achieved through providing clinical supervision. We

suggest that this contributes significantly to the

keenness of academics to continue clinical super-

vision commitments even when they move into the

academy.

The clinical supervision relationship between

academic facilitators and practitioners appears

mutually beneficial for everyone involved. In a dis-

cussion about the defining features of mutuality,

Henson (1997, p. 79) suggest it is:

[...] a feeling of intimacy, connection and understanding

of another. It is a dynamic process characterized by an

exchange between people related to a common goal or

shared purpose.... There is a common language, and

knowledge that enables understanding, exchange, and

involvement of each party.

Josselson (1996, p. 148) notes that in mutuality,

we resonate with one another and this results in

people feeling as though they are thinking together,

feeling together or coping together (p. 154). Given

these defining features that certainly seem to reflect

the experiences of academic staff involved in this

study, the mutual reciprocity, which is perceived to

characterize clinical supervision relationships

probably accounts at least partially for the good

feeling it seems to promote. It also suggests that

academic/practitioner supervision extends beyond

having a purely educative purpose, to fulfil a

restorative function.

It is striking that practitioners seem to be revered

by academics and conversely academics are highly

regarded by practitioners. Perhaps this sense of

mutual respect is fundamental to a successful

relationship. It might be argued that each needs the

other and that neither holds the golden egg of

comprehensive knowledge and skills. However, it

would seem from the focus group that this is not the

perception of either academic supervisors or practice-based supervisees; rather, each prizes the other for

the skills they have, which are perceived as limited in

themselves. Although academics chase the identity

associated with the practice context, it would appear

that some clinicians chase that identity associated

with research and scholarly endeavour accessible

to academics.

Conclusions

This paper has explored the perceived value for

academics and their clinical colleagues of this less

conventional model of clinical supervision. Although

our inquiry is limited, we plant seeds of ideas that we

anticipate will germinate, be tested out, generate

discussion and encourage further research by

colleagues interested in this fascinating area.

Findings suggest that supervising clinical staff

and the vicarious contact with practice that this

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activity brings, affords academics highly prized

affirmation of their professional identity, which

motivates and sustains both their supervision and

teaching work. Academic staff perceive that they

make effective facilitators using transferable skillsdeveloped in the practice setting and augmented by

research and educational skills and knowledge,

which they bring to the relationship and which are

different but complementary to that of clinicians.

They perceive that this is highly valued by their clin-

ical colleagues. Thus, a sense of strong reciprocity

between the two parties emerges from our study,

although we acknowledge a need to extend our

inquiry to explore the perspective of practitioners

first hand to fully understand the dynamic. It is

likely that the potential of this reciprocity between

practitioners and academics is under exploited.

Given the rising demand for skilled clinical super-

vision within health and social care (Driscoll 2007)

and the importance of maintaining clinical identity

to academics, this relationship has the potential to

prove highly fruitful for all concerned.

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. UKCC,

London.

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