Clinical Supervision For Mental Health Nurses
Clinical supervision formental health nursesA framework for Victoria
Clinical supervisionfor mental health nursesA framework for Victoria
To receive this publication in an accessible format phone (03) 9096 7873 using theNational Relay Service 13 36 77 if required, or email ocmhn@dhhs.vic.gov.au.Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne. State of Victoria, Department of Health and Human Services, May 2018.ISBN/ISSN ISBN 978-1-76069-283-4 (Print)ISBN 978-1-76069-284-1 (pdf/online)Available at -mental-health-nursePrinted by Metro Printing, Airport West (1709044)
ContentsAcknowledgements1Foreword2Part 1: Introduction5Why a framework for mental health nurses?6Purpose7Scope7Aims7About the framework7A message from the Australian College of Mental Health Nurses8What is clinical supervision?9Clinical supervision in relation to clinical governance10Clinical supervision: what it is and is not12The clinical supervision relationship18
Part 2: Clinical supervision for mental health nurses in Victoria21Mental health nursing professional practice in Victoria21The framework21A message from the Australian Nursing and Midwifery Federation (Victorian Branch)22Models of clinical supervision24Modes of clinical supervision26Individual supervision26Group supervision29Peer supervision32Principles for effective clinical supervision35Part 3: Implementation and sustainability45Clinical supervision implementation45A message from the Health and Community Services Union46Steps to building a clinical supervision implementation plan49Key roles and responsibilities of the supervisor,the supervisee and the organisation50The way forward56Appendix 1: Background and methodology60References62Further reading64
AcknowledgementsThis framework has been developed with the support of the following people:Expert Reference GroupShelley AndersonChris HermanTom RyanNiels BuusFinbar HopkinsJulie SharrockMichele DoreianGareth JonesPaul SpurrStephen ElsomKate LumsdenBernie Stefan-RasmusMary GilbertPeta MarksKate ThwaitesBridget HamiltonMaggie McIntoshBernadette TownerKerrie HancoxDaniel NichollsRobert TrettKaren HarderMichele PuncherTanya YegdichSue HarveyDarren RiggonProject LeadsJames Houghton, Randolfo ObregonExecutive SponsorAnna Love1
ForewordMental health nurses make up approximatelytwo-thirds of the clinical workforce in Victorianmental health services. The nursing professioncontinues to evolve, particularly in relationto the clinical role and responsibilities, toprovide responsive care and to adapt to policy,practice and service model changes.Over the past decade, a range of initiativeshave been prioritised within Victoria mentalhealth services that have affected the nursingprofession. Some of the key initiatives focus on: delivering care that is consumer-centred,family-inclusive, trauma-informed, recoveryfocused, quality-focused and, above all,safe for all delivering gender-safe and -sensitive practices reducing restrictive practices providing holistic care in response toconsumer needs (for example, dualdiagnosis, family violence, disability).It is important to acknowledge that safetyand wellbeing continue to be a priority forthe government and mental health serviceproviders. Nurses need to be empowered toexpect a safe workplace that is free fromviolence and aggression. They must beleaders in promoting and managing safeworking environments, as well as creatingand maintaining safe clinical and therapeuticspaces for the mental health consumers intheir care. This is particularly challenging inmental healthcare settings where consumers’rights and freedoms are overridden undermental health law.This framework has been developed under theguidance of experts in clinical supervision tohelp you – the nurse – to deal with issues thatarise for you in your work; it will support andenable you to grow as an individual and as aprofessional.It also provides an essential standardisedstructure to support mental health servicesto integrate clinical supervision as part ofevery nurse’s professional role and providesa foundation upon which clinical supervisioncan be integrated into continuous professionaldevelopment.2Clinical supervision for mental health nurses
Whether you are a recently graduated enrolledor registered nurse, an experienced nurse unitmanager or the manager of a mental healthservice, this document outlines the roles andresponsibilities for providing and receivingclinical supervision that incorporates bestpractice principles and recognises the need forflexibility in delivering clinical supervision.It is important to acknowledge thatthis document is consistent with andcomplementary to clinical supervisiondirections set by the: Supervision guidelines for nursing andmidwifery – Nursing and Midwifery Boardof Australia Joint clinical supervision position statement– Australian College of Nursing andAustralian College of Mental Health Nursing.Clinical supervision should be universallyconsidered part of the core business ofcontemporary professional nursing practice.Anna Love – Chief Mental Health NurseDepartment of Health and Human Services3
4Clinical supervision for mental health nurses
Part 1: IntroductionThis framework outlines the Department ofHealth and Human Services’ commitment tosupporting mental health nurses in Victoria inaccessing consistent, appropriate and effectiveclinical supervision and support mechanisms.It is underpinned by an integrative literaturereview, which looked at literature from 2010onwards, including several organisationalpolicies and position statements. Theframework development was steered by agroup of experienced mental health nursesand nurse academics who hold specialistknowledge in providing clinical supervision.A framework is a structured presentation ofideas that enables the observer to identifyand retain information and to communicatethat information to others. Additionally, aframework such as this should support ongoingassessment and reframing of the most recentdevelopments in a given field or professionand include all interrelated informationand knowledge. A framework that has beencarefully chosen or developed will identifyobjectives and purposeful activities, help todetermine which are the most important onesto implement and when, and support theimplementation of identified project strategies.Mental health consumers have a right toexpect safe, competent, strengths- andevidence-based nursing care at all times.As the scope of practice for mental healthnurses continues to develop and expand inrelation to care and clinical interventions,clinical supervision is increasingly consideredan essential aspect of professional practice.Clinical supervision is considered by many tobe part of the core business of contemporaryprofessional nursing practice. It has emergedas a means of using reflective practice andshared experiences to support continuousprofessional development. Proponents ofclinical supervision suggest it provides astructured approach to deeper reflectionon clinical practice that may lead toimprovements in practice and consumer care,and contribute to clinical risk managementand service quality improvements.5
Clinical supervision provides an opportunityfor mental health nurses to further developenhanced reflective skills that are essential tocontinued advancing practice and contributeto improvements in the safety of their nursinginterventions.This framework is designed to supportindividual nurses to meet their clinicalsupervision needs and to contribute positivelyto evolving mental health services.Using this framework as a foundation, localservices can further develop relevant, servicespecific guidelines.Why a framework for mentalhealth nurses?In general, international literature typicallysupports the idea that mental health nursingis a highly specialised field of nursing thatfocuses on working with consumers to meettheir recovery goals. Mental health nursesconsider the person’s physical, psychological,social and spiritual needs, within the contextof the person’s lived experience and inpartnership with their family, significantothers and the broader community. Whilemost professional disciplines working inmental health appear to have seamlesslyadopted clinical supervision, written it intotheir curricula and included it as an essentialcomponent of professional development,there appears to be longstanding resistanceto its inclusion in nursing. The literaturestrongly supports the contention that there6Clinical supervision for mental health nurseshas been prolonged debate and manypublications that focus on the challengesand barriers to providing clinical supervision(Butterworth et al. 2008; Long et al. 2014).Additionally, clinical supervision is not easyto investigate scientifically (Gonge & Buus2015), yet these debates and analyses appearto have done little to improve the qualityand efficacy of clinical supervision beingprovided. The explanation for this dichotomyis multifactorial but includes such issues asthe barriers to access for shiftworkers, thepaucity of accredited, regulated training inclinical supervision and a serious shortage ofrigorous evaluation of outcome methods. Theliterature also strongly suggests that one ofthe key facilitating factors is a clear, detailed,specific mandate (Falendar 2014) at all levelsof management within organisations thatprovide mental health services that supportsthe delivery and uptake of clinical supervisionby all nursing staff. Ironically, there is littleevidence to support the claim that clinicalsupervision is an essential part of best practicefor consumer care (White 2016).Increases in professional responsibility andaccountability and increases in the complexityof modern clinical practice, when combinedwith a lack of clinical support, can potentiallylead to greater numbers of clinical errors andhigher staff turnover than would otherwisebe expected (Caine & Jackson 2011). Goodquality clinical supervision can minimisethe negative effects of these stressors andcomplexities by supporting nurses to access
increased learning opportunities, which inturn will help them develop new skills whileincreasing their connectivity with other teammembers. Supporters of clinical supervisionhave suggested that these positive outcomescan lead to an enhanced sense of professionalwellbeing and may ultimately lead to areduction in the number of people leavingnursing and looking for either new careers orfocusing their nursing career development innon-clinical areas. Additional and more rigorousresearch is needed to verify these claims.The content and approach to clinicalsupervision may need to evolve to matchadvances in nursing practice and theincreasing experience of a mental health nurseover a career.Aims To outline key considerations for theestablishment and sustainability of clinicalsupervision for nurses in Victorian mentalhealth services. To delineate the essential roles andresponsibilities of all stakeholders in clinicalsupervision. To support nurses and services to buildcapacity, skills and competency within themental health nursing workforce in respectof clinical supervision. Ultimately this isexpected to meet the needs of the individualnurses and contribute positively to evolvingmental health services. To identify barriers and opportunities toimplementing clinical supervision for mentalhealth nurses across Victoria.PurposeAbout the frameworkThe purpose of this document is to providea formal framework for individuals andorganisations to develop, implement andevaluate clinical supervision for nurses inVictorian mental health services.The information provided in this frameworkis intended as general information and notas legal advice. Senior mental health nurses,nurse unit managers and mental healthservice managers should ensure that clinicalsupervision practices are developed andimplemented consistently with the purposeand intent of the framework.ScopeThe framework is intended to support allnurses working in Victorian public mentalhealth services and is a guide for privatemental health services and external clinicalsupervision providers.7
Australian College of Mental Health NursesAs anyone who knows me will attest, I am passionate about strengthening the nursingprofession and, in particular, mental health nurses. Clinical supervision is a cornerstone ofprofessional development, individually and collectively. I have been providing and receivingclinical supervision for many years with both mental health and other nurses. My personalgrowth through working and learning with others has been enormous. Clinical supervisionbenefits both the giver and the receiver. Importantly, as each individual grows, so doesthe strength of the profession, because robust, resilient nurses are able to invest more ofthemselves without feeling overwhelmed and exhausted, leading to better outcomes forpeople who receive mental health nursing care. Research has clearly shown the positiveoutcomes of supervision in validating personal and professional concerns – in re-establishingconfidence and efficacy and in learning new and innovative ways of delivering care throughreflection of self and our role.Clinical supervision is an active process and requires active engagement from individuals,the profession itself and organisations. However, getting started is sometimes difficult. Thisframework offers theoretical input as well as guidance to achieve a systematic and solidapproach to delivering clinical supervision. It sets out clear standards and outcomes forclinical supervision to enable and empower mental health nurses to be the best they possiblycan be.Importantly though, it identifies the elements that go together to make clinical supervisionpossible from an organisational point of view. Leaders in organisations may have goodintentions regarding clinical supervision but are often hampered because they are uncertainof the requirements that need to be applied and the policies and processes that inform andguide its implementation.The Department of Health and Human Services is to be congratulated for compiling thisframework. It sets the standard for, and the expectations of, mental health nurses and theirleaders to commit to embedding and sustaining clinical supervision in everyday practice as acore feature of the professional mental health nursing role.Wendy Cross – Former president, Australian College of Mental Health Nurses8Clinical supervision for mental health nurses
What is clinical supervision?Clinical supervision is a process of professionalsupport and learning in which nurses areassisted to develop their practice throughregular time spent in reflective discussion withexperienced and knowledgeable colleagueswho are adequately trained in providingclinical supervision. This is done by way ofa voluntary working alliance between twoor more staff members, where the primaryintention of the interaction is to enhance theknowledge, skills and attitudes of at least onestaff member.Other definitions of clinical supervision include: Clinical supervision is a facilitated exchangebetween practising professionals to enablethe development of professional skills(Faugier & Butterworth 1994). Clinical supervision is a structured process toreflect on clinical practice in order to more fullyappreciate the meaning of the experience,to develop abilities, maintain standards ofpractice and provide a more therapeuticservice to the client (Consedine 1995). Lynch and colleagues (2008) suggest thatcommon concepts of clinical supervisioninclude (but are not limited to) it being asupportive space for the individual clinicianto reflect on their professional practice insuch a way that growth, development andlearning are promoted; that the essentialingredient in the process of establishingclinical supervision is the relationshipbetween the supervisor and the supervisee,and it is this relationship that will influencethe outcome of clinical supervision; and thatclinical supervision is participated in on avoluntary basis and that all parties involvedin supervision need to be fully committed toan open, honest process. On its website, ‘Clinical Supervision in theAlcohol and Other Drugs and CommunityManaged Mental Health Sector’, The BouverieCentre (2013) makes the following statement:9
Though definitions of clinical supervision vary,the principal aims described in the literatureare fairly consistent and can be summarisedas follows: to enhance supervisees’ skills,competence and confidence; to provide areflective space and emotional support;to provide assistance with professionaldevelopment; to ensure that services toclients is safe, ethical and competent; toensure compliance with professional andorganisational treatment standards & practice.Clinical supervision in relationto clinical governanceClinical supervision is one component of a widerframework of clinical governance activities thatare designed to support staff and to manageand monitor the delivery of high-qualityservices and effective outcomes for mentalhealth service consumers. Other componentsinclude administration, line management,performance appraisal, developmentprocesses, mentoring, clinical education/training and participation in structures suchas clinical reviews, team meetings, mentoring,clinical handovers and grand rounds.10Clinical supervision for mental health nurses
Figure 1: A model of clinical governance and professional developmentSource: Adapted from Queensland Health 2009, Clinical Supervision Guidelines for Mental Health ServicesClinical review, teammeetings, handovers,grand roundsAdministration,line management,supervisionClinicalsupervisionClinical governance,professionaldevelopmentPerformance appraisal,development plansClinical educationand trainingMentoring11
Clinical supervision:what it is and is notThe literature and the findings of consultationswith clinicians experienced in receiving andproviding supervision highlighted that clinicalsupervision is not a management activity andshould not be confused with performanceappraisal or administrative supervisionwith line managers. Elements associatedwith clinical supervision include consumerfocused, clinician-led, practice-focused,intraprofessional or cross-professional workthat is delivered in a variety of modes. Clinicalsupervision is distinct from a line managementtool, a method of surveillance, a formalperformance review, a form of preceptorship,a form of therapy, a form of training, a formof mentoring or a compulsory element ofemployment and is neither counselling norhierarchical (see Figure 2).12Clinical supervision for mental health nursesAs described in the New South Wales HealthEducation and Training Institute (HETI) documentA supervision continuum for nurses andmidwives, there are a range of supervision typesthat can be used throughout the professionaldevelopment of nurses and midwives, dependingon individual professional development needs.The topics covered in the HETI supervisioncontinuum include (see also Table 1): point of care – clinical teaching, clinicalfacilitation, preceptorship, buddying facilitated professional development –peer review, coaching, mentoring clinical supervision (reflective).
Figure 2: Clinical supervision: what it is and what it is notWHAT IT ISWHAT IT IS NOT Consumer-focused – reflect onissues relating to, or affecting,clinical practice and the delivery ofconsumer care Clinician-led – the clinician choosesthe supervisor and determines thefrequency, the purpose and thefocus for each session and their ownlearning goals Practice-focused – focus on clinicalpractice issues associated withservice delivery Intra-professional (conducted bymembers of the same profession) orcross-professional (conducted by amember of another profession) Delivered in a variety of modesincluding face-to-face, telephoneand videoconferencing, and in eitherindividual or group format A line management toolA method of surveillanceA formal performance reviewA form of preceptorshipCounsellingHierarchicalCriticism of the individualas a nurse or a personA form of therapyA form of trainingMentoringCompulsory for employment13
Table 1: Types of supervision for nurses and midwivesClinicalsupervisionMethod ofprovisionPoint-of-care supervisionClinical facilitationBuddyingPreceptoringClinical teachingSupervision andsupport of nursingand midwiferystudents duringclinical placementWelcome andorientation tothe new workenvironmentEducation onspecific clinical andnon-clinical skillsInformalClinical supportfor new staffduring thetransition to a newwork lIndividualIndividual or ual or groupShort–mediumtermShort term(approximatelyfirst three months)Short term(approximatelythree–six months)Short termFeedback tostudentFeedback to newstaff member andNUM/MUMFeedback to thepreceptee andNUM/MUMFeedback to thelearner and NUM/MUM as requiredMay includefeedback to aneducation provider14OpportunisticClinical supervision for mental health nursesEpisodic/planned
Facilitated professional developmentClinical supervision(reflective)Peer reviewCoachingMentoringClinical supervisionEvaluation of care by acolleague of a similarlevel of experience andpositionDevelopment ofspecific skills andknowledge to attainidentified goalSenior professionalshares knowledge andexpertise to nurtureprofessional growthReflection on work andprofessional lIndividual or groupIndividual or groupIndividual – instigatedby the mentoreeShort–medium term(at regular intervals orin response to need)Short termLong term (frequencyflexible according toneed/availability)Long term (monthly)Feedback to peer(s)Feedback to coacheeFeedback to menteeNUM/MUM awarenessof peer review processMay include feedbackto managerManager may beinformed by menteeFeedback tosupervisee(s)Formal/structuredIndividual or group15
Table 1: Types of supervision for nurses and midwives t-of-care supervisionClinical facilitationBuddyingPreceptoringClinical teachingSafe patient careduring studentlearningQuickerintegrationinto the workenvironmentIncreasedknowledge,clinical skills andapplication oftheory to practiceIncreasedknowledge,clinical skills andapplication oftheory to practiceSafe clinicalpractice andsupportedtransition to workenvironmentSafe clinicalpracticeApplicationof skills andknowledge topracticeFeedback,guidance andencouragementto continuedevelopmentInteractions withNUM/MUM aremore focused onkey areasIncreasedopportunity forconnection withother ng towardscompetencyattainmentExamplesObservation ofdirect patientcare and indirectcare by RN/RM inaccordance withstudent’s levelof training andexperienceOrientation tophysical workenvironmentNew staff memberable to askquestions freelyCase discussion/reviewOrientationto clinicalprocedures andprocessesSupport toachieve learninggoalsObservation ofcompetency andtransitionTeachingopportunities: direct patientcare at clinicalhandover during wardrounds educationsessionsDebriefingSource: Health Education and Training Institute 2013, The Superguide: a supervision continuum for nurses and midwives16Clinical supervision for mental health nurses
Facilitated professional developmentClinical supervision(reflective)Peer reviewCoachingMentoringClinical supervisionQuality and safe careFocused support in theattainment of goalsExtended supportin the attainment ofgoalsImproved clinicalpractice y andenhancementProfessionaldevelopmentMeasuring practiceagainst professionalstandards of practiceReview of medicationerrors and fallsAuditing offiles to improvedocumentationCase reviewRoot cause analysisEmpowering andenablingImprovedperformance andwellbeingDevelopment of futureleadersFurther developmentof capacity and skillsSustaineddevelopment ofleadersMore reflective,vibrant professionalstaff membersAction Learning SetsMentoring programsLeadershipdevelopmentDevelopment ofmanagers and clinicalleadersClinical leadershipprograms including‘Take the Lead’ (formanagers)Exploring newways of working ordealing with difficultsituationsIndividual or groupsupervision with atrained supervisorPeer supervision17
The clinical supervisionrelationshipThe effectiveness of clinical supervision isa direct result of the quality of the clinicalsupervision relationship (Bond & Holland 2010).Achieving a quality relationship is predominantlyreliant on the skill and expertise of thesupervisor. For this reason, it is imperative thatsupervisors receive appropriate theoretical andpractical preparation (Lynch et al. 2008). Therole of the supervisee is also important in orderto build the relationship and to gain the mostout of the experience. It is important, therefore,that all participants have a good understandingof the supervision process and that the clinicalsupervision relationship develops into aneffective working alliance (Bond & Holland 2010).18Clinical supervision for mental health nurses
19
20Clinical supervision for mental health nurses
Part 2: Clinical supervision formental health nurses in VictoriaMental health nursingprofessional practicein VictoriaA number of defined and variable factors affectthe professional practice of mental healthnurses working in Victoria (see Figure 3). Definedrequirements include legislation, professionalrequirements, policy and procedures, amongothers. Variable requirements can range fromclinical and service settings (bed-based servicesand community teams), to location (metropolitan,regional and rural), client groups (child and youth,adult and aged), acuity of illness and workplacesettings (clinical, management and academic).For these reasons, it is essential to develop aframework that accommodates the complexrequirements for mental health nurses.The frameworkThis framework is intended to help guideindividual Victorian mental health nurses toengage in clinical supervision and to guidemental health service organisations to identifyfactors that could support increased uptakeand more effective implementation of clinicalsupervision across the state. The frameworkalso clarifies the key practice principles thatshould underpin the implementation anddelivery of clinical supervision to ensure thatthe highest quality of mental health nursingcan be delivered to consumers. The frameworkshould be considered as complementary toexisting professional standards, organisationalpolicies and associated legislation.The elements of this framework are derivedfrom an integrative literature review anda nationwide consultative process with anexpert reference group, the combination ofwhich led to a set of overarching principlesand philosophy for clinical supervision.The consultation process resulted in thespecification of various practice parameterspertaining to three domains: the supervisee – any mental healthnurse working in a clinical area or nondirect clinical care such as coordinators,managers, educators and researchers the supervisor – a person with experience andtraining as a supervisor of clinical supervision the organisation – any employer ofmental health nurses.21
Australian Nursing and Midwifery Federation (Victorian Branch)ANMF (Vic Branch) members who are engaged in agreed and effective clinical supervisionregularly report professional development benefits arising from having time to reflect on theirpractice, particularly when employed in what is often a challenging environment. ANMF (VicBranch) advocates for upholding the underpinning principles of clinical supervision includingaccessible, safe, confidential and voluntary arrangements with appropriately trained clinicalsupervisors. An equally important principle – and one that is emphasised in the mental healthnurses’ industrial instrument – is that the clinical supervision offered to nurses is providedby a supervisor of the nurse’s choice.Nurses employed in Victorian public mental health services have a workplace right to accessprofessional (clinical) supervision up to two hours per month, with provisions that enableemployers to offer additional time. Clinical supervision is also a critical element of theRPN 2 community training provisions with the framework for clinical supervision requiringorganisations to collaborate on the development of effective implementation plans.As an industrial entitlement, all parties – including employers, the Department of Health andHuman Services and ANMF (Vic Branch) – have a role to play in supporting the workforce andensuring improved access to clinical supervision for mental health nurses.As indicated in the Joint clinical supervision position statement, employers must positivelysupport and actively promote demonstrable and effective clinical supervision throughorganisational policies, procedures and workplace culture.Lisa Fitzpatrick – Secretary, ANMF (Vic Branch)22Clinical supervision for mental health nurses
Figure 3: Factors affecting mental health nurse professional practice in VictoriaOrganisation Legislation and policyService model policies and proceduresQuality and safety clinical standardsOccupational Health SafetyHuman Resources policiesRecords management and reporting Victoria’s Mental Health Act 2014Reducing Restrictive PracticesHealth Records ActHuman Rights CharterVic. Chief Psychiatrist Guidelines and cmientdnariccl/hACro/Regional/RuralChildVictorian MentalHealth NursesClinical specialty:youth/Adult/Foreandnsic/iaDual d gnosisRoles:Meterience/grade:Expate/Grade 1-7/Na duursGretioPracti nerConsumer centred care Recovery oriented practiceTrauma informed careCultural safetyFamily inclusive practiceSupported decision makin
Mental health nursing professional practice in Victoria 21 The framework 21 A message from the Australian Nursing and Midwifery Federation (Victorian Branch) 22 . Peer supervision 32 Principles for effective clinical supervision 35 Part 3: Implementation and sustainability 45 Clinical supervision implementation 45 A message from the Health .
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supervision). KEYWORDS. Clinical supervision, conceptual model, systematic review One of the major challenges hindering the further development of clinical supervision has been poor conceptualization in both theory and empirical studies: Clarifying what clinical supervision is and how it works. Supervision theories have historically been derived
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13.19 Voltage-Transformer Circuit Breaker 1032 13.20 Voltage-Balance Supervision 1033 13.21 Voltage-Sum Supervision 1034 13.22 Voltage Phase-Rotation Supervision 1035 13.23 Current-Balance Supervision 1036 13.24 Current-Sum Supervision 1037 13.25 Current Phase-Rotation Supervision 1038 13.26 Temperature Supervision 1039
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