Clinical Supervision: invisibility on the contemporary nursing and midwifery policy agenda

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Over the last two decades or so, Clinical Supervision (CS) has entered the folklore of nursing and midwifery professions (White & Winstanley 2014) and is exalted in public policy statements. In one discrete area, creditable research evidence has accumulated to demonstrate that CS has a positive effect on the well‐being of supervisees and that workplace burnout can be ameliorated. This relatively uncontested relationship is dependent, however, on the quality of the CS being provided being of a demonstrably efficacious standard. This caveat is often overlooked or ignored, notwithstanding the availability of new methodological techniques to test such efficacy and to predict the best outcomes, given local circumstances (Winstanley & White 2014). More commonly, I suspect, the contemporary preoccupation is to document the volume of CS activity in a somewhat perfunctory manner; that is, to count how many staff access CS in local settings, at what frequency and duration, and whether key performance indicator targets have been met. It is not uncommon in settings where uptake of CS is low, even absent, that a lack of available time is often cited as an impediment. Sometimes, however, the paradox gets lost; viz, for staff who face increased health service austerity and increased work pressures, the argument for efficacious CS becomes stronger, not weaker. Furthermore, other important questions receive scant attention; what are the measurable effects of CS and at what cost? It is assumed, for example, that CS may improve the quality of care provided to patients and, in a causally related manner, CS may improve patient‐reported outcomes. It is also assumed that CS may be instrumental in, say, the reduction of (costly) staff turnover rates. In my opinion, these remain hypothetical propositions, worthy of rigorous testing and reporting.
Clinical supervision is often accepted as a formal relationship‐based system of support and practice development provided by approved Supervisors to the staff in human service agencies to maximize the best possible outcomes for their respective clientele. However, operational definitions of CS have not been without ambiguity, contest and international differences (White et al. 1993, Milne 2007). In recent times, and in deference to predominant managerial and medical training agendas, CS has become spuriously used as a tautological synonym for coaching, mentorship, peer review, clinical facilitation, preceptorship, clinical teaching, buddying, debriefing and other oversight/point‐of‐care encounters. Not uncommonly, the term is also used as a byword for ‘personal performance review', case review and even therapy. I have expressed concern about such ‘muddying of the waters' and the attendant risk whereby, in changing the nomenclature, the nursing and midwifery professions may eventually lose control of the CS narrative (White 2014).
Although CS is frequently cited in health service governance reports and position statements of many, if not most, health and social care professional organisations, evidence‐based guidelines about how best it should be delivered and evaluated have remained insufficient. Furthermore, a commitment to sponsor empirical investigations to review, regularly, the efficacy of CS arrangements in local, regional or national settings, appears reluctant. It is also the case that rigorous, large‐scale, quantitative research studies are a challenge to design, conduct and interpret (White 2016). In relation to nursing and midwifery, with rare exceptions (White and Winstanley 2010), it follows that the international literature is replete with accounts from studies with small (even tiny) sample sizes, which rest at the level of qualitative description, and in which the lack of empirical evidence continues to be lamented.
The landmark Clinical Supervision Evaluation Project (CSEP; Butterworth et al.
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