Clinical Supervision Policy
May 2013
Clinical Supervision
Version 2.0 May 2013
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Table of Contents
1.
Introduction ................................................................................................................... 3
2.
Purpose of this Policy/Procedure .................................................................................. 4
3.
Scope ........................................................................................................................... 4
4.
Definitions / Glossary .................................................................................................... 4
5.
Ownership and Responsibilities .................................................................................... 5
5.1.
Role of the Managers ............................................................................................ 5
5.2.
Role of the Learning and Development Department .............................................. 5
5.3.
Role of Individual Staff ........................................................................................... 6
5.4.
Role of Supervisors/coaches ................................................................................. 6
6.
Standards and Practice ................................................................................................ 6
6.1.
Principles of Supervision ....................................................................................... 6
6.2.
Informal Supervision .............................................................................................. 7
6.3.
Group Supervision ................................................................................................. 7
6.4.
Process for requesting supervision........................................................................ 7
6.5.
Supervision for Nurses and Midwives at band 7 and above .................................. 7
6.6.
Confidentiality ........................................................................................................ 7
6.7.
Documentation and Reporting ............................................................................... 8
6.8.
Supervision and Development for Supervisors ...................................................... 8
7.
Dissemination and Implementation ............................................................................... 8
8.
Monitoring compliance and effectiveness ..................................................................... 9
9.
Updating and Review.................................................................................................... 9
10.
Equality and Diversity ................................................................................................ 9
10.1.
General Statement ............................................................................................. 9
10.2.
Equality Impact Assessment ............................................................................ 10
Appendix 1. Governance Information ................................................................................ 11
Appendix 2.Initial Equality Impact Assessment Screening Form ....................................... 13
Appendix 3. Process for requesting Individual Supervision ............................................... 15
Appendix 4 Process for requesting Group Supervision ..................................................... 16
Appendix 5 Record of Supervision Activity ........................................................................ 17
Appendix 6. Supervision Record ........................................................................................ 18
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1. Introduction
1.1. Clinical supervision is a process by which professionals are assisted to improve
practice, develop both professionally and personally, and manage complex situations
associated with the care and treatment of patients. It is a method of supporting and
developing competence by providing practitioners with the opportunity to meet on
either a regular or an ad hoc basis with an experienced colleague to discuss and
reflect upon and learn from their experiences in clinical practice.
1.2. There are many definitions and models relating to clinical supervision. The
following definition from the Nursing & Midwifery Council (2006) is useful in health
care settings.
1.3. ‘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 safety of care in complex
situations’ (NMC 2006 p6)
1.4. The value of effective professional supervision is recognised by the majority of
health associated bodies such as the Nursing and Midwifery Council, Chartered
Society of Physiotherapists etc.
1.5. It is a statutory requirement for midwives to undergo annual midwifery
supervision review at least once per year with a named midwifery supervisor. The
purpose of Midwifery supervision is to provide a mechanism for support and guidance
to every practising midwife in the United Kingdom and to protect women and babies
by actively promoting a safe standard of midwifery practice. Supervisors of Midwives
are appointed by, and are accountable to, the Local Supervising Authority (NMC
2012).
1.6. Therefore, clinical supervision as defined within this document is distinct and
different to midwifery supervision. Midwives are required to continue with their formal
professional supervisory arrangements but may choose to participate in additional
supervision as identified in this document.
1.7. Coaching and mentoring are also recognised as an effective means of
supporting individuals to develop both personally and professionally. Coaching and
mentoring can be defined as ‘learning relationships which help people to take charge
of their own development, to release their potential and to achieve results which they
value’ (Connor & Pokora 2007 p11)
1.8. Whilst coaching and mentoring can be viewed as complementary and have
many similarities, such as facilitating insight, learning and change through a one to
one relationship, there are some more distinct differences between the two
approaches. Mentoring is often undertaken by a more senior person who has
experience or achieved success within the same field as the ‘mentee’ and may
include a level of professional guidance direction and support. Coaching can be
undertaken by an individual who does not have experience within the same field as
the ‘coachee’ and is more focused on facilitating the coachee to find their own
answers and potential.
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1.9. Clearly, coaching and mentoring can be used to support individuals within any
work setting whereas clinical supervision is aimed specifically at staff working in
clinical settings. However many of the principles and outcomes are similar to that
being achieved through supervision. Consequently, whilst accepting the differences
between coaching, mentoring and clinical supervision, RCHT acknowledges that all
these processes ultimately fulfil the requirements of staff for supervision and
development.
1.10. Therefore, for the purpose of this document, the term ‘supervision’ and
‘supervisee’ are utilised. These are used as inclusive terms and could equally refer to
coaching and mentoring processes.
1.11. This version supersedes any previous versions of this document.
2. Purpose of this Policy/Procedure
This policy aims, firstly, to provide a clear understanding of supervisory processes at
RCHT that focus on the personal and professional development of staff (excluding
medical and dental staff). Secondly, it provides a framework for reporting of
supervisory activity undertaken at RCHT which can then be reported for governance
purposes.
3. Scope
3.1. This policy applies to all health professionals, (excluding doctors and
dentists), and clinical support staff employed at The Royal Cornwall Hospitals
NHS Trust.
3.2. Clinical supervision does not seek to replace managerial supervision. The
role of the line manager in providing supervision for their staff is an important
part of ensuring effective performance is maintained. Clinical supervision is an
additional means of support and development to that of line management.
4. Definitions / Glossary
Term
Clinical supervision
Meaning
‘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
safety of care in complex situations’
(NMC 2006 p6)
Coaching/Mentoring
‘Learning relationships which help
people to take charge of their own
development, to release their potential
and to achieve results which they
value’ (Connor & Pokora 2007 p 11)
Mentoring is often undertaken by a more
senior person who has experience or
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achieved success within the same field as
the ‘mentee’ and may include a level of
professional guidance direction and
support. Coaching can be undertaken by
an individual who does not have
experience within the same field as the
‘coachee’ and is more focused on
facilitating the coachee to find their own
answers and potential.
The body designated in the Nursing
and Midwifery Order (2001) as
responsible for exercising general
supervision over all midwives practising
within its area.
Managerial supervision refers to the
support and guidance provided by a
line manager to a direct report that
enables them to undertake the day to
day operational aspects of their role.
A statutory responsibility which
provides a mechanism for support and
guidance to midwives with the aim of
protecting women and babies by
actively promoting a safe standard of
midwifery practice (NMC 2009) .
A person receiving support and help to
develop through supervision, coaching
or mentoring
A person working with another
individual to help them develop
personally and professionally through
the processes of supervision, coaching
or mentoring
Local Supervising Authority
Managerial supervision
Midwifery supervision
Supervisee/coachee/mentee
Supervisor/coach/mentor
5. Ownership and Responsibilities
5.1. Role of the Managers
Line managers are responsible for:



Recognising the benefits that clinical supervision provides for staff and
highlighting staff for whom this would be a particularly useful mode of personal
and professional development.
Providing time for clinical supervision within working hours
Providing on-going managerial supervision for all their staff
5.2. Role of the Learning and Development Department
The Learning and Development Department is responsible for:

Ensuring that the Trust website contains an up-to-date list of recognised
supervisors available for the supervision of others.
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



Ensuring that supervisors are aware of reporting arrangements to collect data
relating to supervisory activity
Collect data regarding supervisory activity at RCHT
Provision of training, development and support for current and future
supervisors/coaches
Supporting staff to access a supervisor if required
5.3. Role of Individual Staff
All staff members are responsible for:





Actively engaging in clinical supervision activities in accordance with the
requirements from their professional body.
Ensuring that they take up supervision to meet their personal and professional
development needs
Recognising that supervision is a positive and effective means of improving
performance and supporting development. It is not solely aimed at improving
poor performance.
The direction of their supervision and identification of areas of practice that
could be explored in a supervisory session.
Maintaining a record of learning from supervision/coaching in their personal
professional portfolio
5.4. Role of Supervisors/coaches






Providing an environment in which the supervisee feels safe to explore
potentially difficult situations, behaviours and attitudes
Ensuring that they focus on the developmental needs of the supervisee and
maintain a non-judgemental approach.
Utilise appropriate skills to ensure that supervision sessions are effective and
purposeful.
Agree with supervisee at the outset regarding any communication that will take
place with the supervisee’s line manager
Maintain supervision/coaching records
Complete a record of supervisory activity and return this to the Learning and
Development Department quarterly
6. Standards and Practice
6.1. Principles of Supervision
The Chartered Society of Physiotherapy (2005) define the principles of supervision as
follows:





Support and enhance practice for the benefit of patients
Develop skills in reflection to narrow the gap between theory and practice
Involve a supervisor and practitioner/group of practitioners reflecting on and
critically evaluating practice
Be distinct from formal line management supervision and appraisal
Be planned and systematic and conducted within agreed boundaries
Be explicit about the public and confidential elements of the process
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
Define an outcomes based action plan. The outcomes can then be more
broadly developed to assist the practitioner’s professional development through
the Performance Development Review (PDR) process with their line
manager/reviewer.
6.2. Informal Supervision
Whilst this policy focuses on the provision of supervision in a formal setting, it is
acknowledged that some staff participate in informal supervision with colleagues
outside the work setting. This can be a valuable learning experience; however, RCHT
encourages staff to engage in formal supervision to ensure that it remains a
meaningful and constructive process and to gain maximum benefit for patient care.
Episodes of informal supervision are not recorded as supervision activity at RCHT.
6.3. Group Supervision
Supervision can be undertaken as an individual practitioner or with a group of
practitioners. A group can consist of singular or mixed professional/occupational
groups. The principles of group supervision are the same as that of individual
supervision. However, greater consideration needs to be made to the establishment of
ground rules at the start of the process and there should be a shared common
purpose between the group members.
6.4. Process for requesting supervision
The processes for requesting individual and group supervision are outlined in a flow
chart in appendices 3 and 4 respectively.
6.5. Supervision for Nurses and Midwives at band 7 and above
6.5.1 The Nursing and Midwifery Strategy 2013 encourages the participation of all
nurses and midwives in clinical supervision. However, the strategy identifies a
mandatory requirement for all nurses and midwives at band 7 or above to undertake
clinical supervision.
6.5.2 It is the responsibility of each individual nurse/midwife to make arrangements
for their supervision which can be undertaken on an individual basis or as part of a
group. Nurses/midwives who are undertaking a coaching programme need not also
participate in clinical supervision unless they specifically choose to do so.
Nurses/midwives at band 7 or above are expected to undertake a minimum of two
clinical supervision sessions per year.
6.6. Confidentiality
6.6.1 The supervision process is confidential between the supervisor and the
supervisee. Any discussion of the content of a supervision session should not be
discussed outside of the session without the agreement of both parties.
6.6.2 However, should a situation arise where maintaining confidentiality would put
patients or others at risk of harm, the supervisor is required to take appropriate
action.
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6.7. Documentation and Reporting
6.7.1 As a minimum the supervisor must record the date, time name and
workplace of supervisee on the supervision record sheet (appendix 5) for all
supervision sessions. Before starting supervision with an individual or group the
supervisor must explain that this type of record of their supervision will be
maintained and used in reports to demonstrate levels of supervision activity at
RCHT. These reports do not include the names of individual supervisees nor do
they contain any detail of the content of a supervision session. They simply record
that the activity has taken place.
6.7.2 Supervisors are encouraged to maintain records of their supervision session
although this should be agreed with their supervisee at the start of the process.
Supervisor records are encouraged as they form a useful reference point for future
session, are helpful in the evaluation of progress and are a reminder regarding the
agreement of actions. Supervisors may develop their own record template or utilise
the one found at appendix 6.
6.7.3 Supervisees are encouraged to keep records of supervision for their
personal professional portfolio. In this instance any reference to patient care/
colleagues/visitors etc should be anonymous. Written reflections on learning that
has taken place as a result of supervision are encouraged.
6.8. Supervision and Development for Supervisors
6.8.1 Supervisors for registered professionals will have a minimum of two years
post registration experience and will undertake a form of taught preparation for
their role. This could be a coaching course (or equivalent) with external
accreditation but may also be an internal preparatory programme.
6.8.2 Supervisors for non-registered professionals will have a minimum of 5 years
experience within a healthcare setting (or related field) and will have completed a
form of taught preparation for their supervisory role. This could be a coaching
course (or equivalent) with external accreditation but may also be an internal
preparatory programme.
6.8.3 Supervisors are accountable for their own development and support.
However, they are advised to meet formally with a fellow supervisor at least once
yearly for personal development and reflection upon their supervisory skills.
Supervisors should hold a personal record of this meeting.
6.8.4 A learning needs analysis for supervisors is carried out by the learning and
development department on a bi-annual basis. Bespoke training programme to
meet identified needs will then be developed and implemented.
7. Dissemination and Implementation
7.1. This policy will be disseminated via the document library on the RCHT Intranet
site.
7.2. Implementation of the policy is undertaken by individual staff members in
partnership with named supervisors and the Learning and Development
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Department.
8. Monitoring compliance and effectiveness
Element to be
monitored
The amount of supervision that is undertaken by staff at RCHT will be
monitored quarterly
Lead
The Learning and Development Department will collate reports
detailing the amount of supervision undertaken utilising information
submitted quarterly by supervisors
The reporting form included in this policy at appendix 5 will be used to
collect data for monitoring purposes.
Reporting on supervision activity is completed quarterly and a report
compiled.
Tool
Frequency
Reporting
arrangements
The report will be shared with the HR Governance group, the Senior
Nurse/Midwifery Committee and the Divisional Quality and Learning
Group.
Acting on
All line managers, supervisors and the learning and development
recommendations department will work collaboratively to ensure tat
and Lead(s)
recommendations/actions are completed in a timely manner
Change in
practice and
lessons to be
shared
Any changes to practice /lessons learned will be shared through senior
nurse /midwifery meetings, Learning & Development Departmental
meetings and supervisors training sessions. Where applicable email
communication will also be utilised.
9. Updating and Review
9.1. This policy will be reviewed three yearly or in line with any specific changes to
Professional Body standards/guidelines. Additionally it will be reviewed in line with any
changes to required standards by NHS Monitoring bodies such as NHSLA, CQC etc.
10. Equality and Diversity
10.1. General Statement
Royal Cornwall Hospitals NHS Trust is committed to a Policy of Equal
Opportunities in employment. The aim of this policy is to ensure that no job
applicant or employee receives less favourable treatment because of their race,
colour, nationality, ethnic or national origin, or on the grounds of their age,
gender, gender reassignment, marital status, domestic circumstances, disability,
HIV status, sexual orientation, religion, belief, political affiliation or trade union
membership, social or employment status or is disadvantaged by conditions or
requirements which are not justified by the job to be done. This policy concerns
all aspects of employment for existing staff and potential employees.
This document complies with the above statement.
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10.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
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Appendix 1. Governance Information
Document Title
Clinical Supervision
Date Issued/Approved:
10th February 2014
Date Valid From:
10th February 2014
Date Valid To:
1st February 2017
Directorate / Department responsible
(author/owner):
Helen Lewis, Learning & Development
Department
Contact details:
01872 255148
This policy outlines a process for staff who
wish to undertake supervision to support
their personal and professional
development. It identifies a means of
recording supervision activity at RCHT
Supervision
Coaching
Mentoring
Clinical supervision
RCHT
PCT
CFT

Director of Human Resources and
Organisational Development /Interim
Nurse Executive
Brief summary of contents
Suggested Keywords:
Target Audience
Executive Director responsible for
Policy:
Date revised:
May 2013
This document replaces (exact title of
previous version):
Clinical Supervision Policy & Framework
Senior Nurse/Midwifery Committee
Heads of HR Meeting
JPRG
Coaching, Mentoring & Supervision
Working Group
Approval route (names of
committees)/consultation:
Divisional Manager confirming
approval processes
Interim Nurse Executive
Chair of JCNC Suzanne Grice- Renault
or nominated deputy
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Original copy signed
Internet & Intranet
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 Intranet Only
Ratification):
Document Library Folder/Sub Folder
Clinical -General
Links to key external standards
Care Quality Commission Outcome 14
Chartered Society of Physiotherapy.
(2005) A Guide to Implementing Clinical
Supervision
Connor M, Pokora J (2007) Coaching and
Mentoring at Work: Maidenhead. Open
University Press
Related Documents:
Nursing and Midwifery Council. (2006)
Clinical Supervision
Training Need Identified?
Nursing and Midwifery Council. (2012)
Midwives Rules and Standards
Nursing and Midwifery Council.(2009)
Modern Supervision in Action, a practical
guide for midwives
Yes – supervisors need to undertake a
programme of training to develop a
supervisory role. Following this they may
need further refresher training and
supervision themselves
Version Control Table
Date
Version
No
V1.0
May 2013 V2.0
Summary of Changes
Changes Made by
(Name and Job Title)
Clinical Supervision Policy and
Framework
Sandra Arnold
Practice Development
Clinical Supervision reviewed
Helen Lewis,
Learning &
Development
Department
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
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Appendix 2.Initial Equality Impact Assessment Screening Form
Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed: Clinical Supervision
Directorate and service area:
Is this a new or existing Procedure?
Directorate of Human Resources
An update of a previous policy
Learning & Development Department
Name of individual completing
Telephone:
assessment: Helen Lewis
01872 255148
1. Policy Aim*
This policy aims, firstly, to provide a clear understanding of
supervisory processes at RCHT that focus on the personal
and professional development of staff (excluding medical
and dental staff). Secondly, it provides a framework for
reporting of supervisory activity undertaken at RCHT which
can then be reported for governance purposes.
2. Policy Objectives*
As above
2. Policy – intended
Outcomes*
4. How will you measure
the outcome?
Staff understand the process to access supervision to
support their personal and professional development
Staff recognise the availability of supervision at RCHT
RCHT can clearly define the amount of supervisory
activity that is taking place
Quarterly reports will demonstrate the number of staff
who have undertaken supervision
5. Who is intended to
benefit from the Policy?
Patients, carers and relatives
All staff members
6a. Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around this
policy?
b. If yes, have these
groups been consulted?
c. Please list any groups
who have been consulted
about this procedure.
Consultation has been undertaken with the following groups
of staff/individuals:
Senior Nurse/Midwife Committee
HR Heads of Service/Governance Group
Trust Lead for Leadership and Management
development
Coaching, Mentoring and Supervision working group
Learning and Development Administrative team
leader
JPRG
*Please see Glossary
7. The Impact
Please complete the following table using ticks. You should refer to the EA guidance notes
for areas of possible impact and also the Glossary if needed.
Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the ‘Positive impact’ box.
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Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.
Equality
Group
Age
Positive
Impact
Negative
Impact
No
Impact
X
Disability
X
Religion or
belief
X
Gender
X
Transgender
X
Pregnancy/
Maternity
Race
X
Sexual
Orientation
X
Marriage / Civil
Partnership
X
Reasons for decision
X
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
A negative impact and
No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that the policy
promotes equality, equal opportunities
or improved relations - could it be
adapted so that it does? How?
Full statement of commitment to policy of
equal opportunities is included in the policy
Please sign and date this form.
Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean
House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ
A summary of the results will be published on the Trust’s web site.
Signed ___Helen Lewis_____________________________________
Date ___May 2013______________________________________
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Appendix 3. Process for requesting Individual Supervision
Individual identifies need
for supervision
Need for supervision is
agreed between Line
Manager and Individual
Individual approaches a supervisor directly
and agrees for supervision to commence
or
Individual Line Manager approaches
Learning and Development to request
support in finding a supervisor
Supervision Commences
Records of supervision
episodes are returned to
Learning and
Development quarterly
Records of group
supervision are
maintained by the
supervisor and evaluation
is undertaken as agreed
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Appendix 4 Process for requesting Group Supervision
Individual identifies need
for supervision
Need for supervision is
agreed between Line
Manager and Individual
Individual approaches a supervisor directly
and agrees for supervision to commence
or
Individual Line Manager approaches
Learning and Development to request
support in finding a supervisor
Supervision Commences
Records of supervision
episodes are returned to
Learning and
Development quarterly
Records of group
supervision are
maintained by the
supervisor and evaluation
is undertaken as agreed
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Appendix 5 Record of Supervision Activity
Name of Supervisor____________________________________ Date of Activity from_________________________to ____________________
Date of
supervision
session
Time of supervision
session
Duration of
supervision session
Name of supervisee
Workplace of
supervisee
Evaluation of
supervision
process undertaken
Y/N
This form should be returned to the learning and development department by the following dates each year
For Learning and Development Dept use only
30th June
30th September
31st December
31st March
Data entered onto database ___________date
Name___________________
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Appendix 6. Supervision Record
Confidential between the
supervisor and
supervisee
Name of Supervisor
Name of Supervisee
Date of Supervision session
Supervisee job role & workplace
Start time
Finish time
Session number
Location
Agreed Goals for Session
Summary and context of discussion
Action Points
Reflection on original aims for supervision
Supervisee Feedback/comments
Signature of Supervisee
Signature of Supervisor
Date
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