These guidelines included:

• preparation for the role of clinical supervisor by either completing a registered course programme on clinical supervision, preparation through prior practice experience or a course in which appropriate learning takes place e.g. Counselling.
• A clinical supervisor must receive supervision.
• Job descriptions for qualified staff that identified the knowledge and skills associated with clinical supervision activity as part of the nurses role.
• Undertaking the role of clinical supervisor should be a matter of choice for individual practitioners. Motivation was seen as important.
• Two years clinical experience was a benchmark for the role of clinical supervisor.

Within the Renal Unit, the starting point for clinical supervision was applying for the course to increase our knowledge and develop skills to be able to carry out clinical supervision within our clinical areas. A small number of nursing staff at grade F and above had or were completing the four-day SC140 Clinical Supervision course organised by St Bartholomew's School of Nursing. We completed a Force Field analysis to identify if there was a real need for the implementation of clinical supervision within the Renal Directorate. We found that the driving forces far outweighed the restraining forces. As team leaders we were enthusiastic to be in a position to offer more support for our staff by allowing them the opportunity for reflection on their work. We felt that our clinical practice would be developed to ensure high standards of care in relation to our patients needs. We understood that it was going to be time consuming to free up staff for individual sessions but we were all in agreement that the advantages for all (patients and staff) were greater than the disadvantages. There had been an impetus to start clinical supervision from the Trust and there was a need within the clinical area.

It was felt that we needed an experienced person to supervise this group. Margaret Smith, who worked for many years within the Trust as a social worker manager and co-ordinator for the Trust's Bereavement Service, was approached. Supervision in social work and counselling has been operational for many years and is frequently referred to  when  discussing  clinical supervision for nurses, so we felt that Margaret would have valuable skills and experience from which we could learn and develop. Initial meetings were set up with two groups consisting of 4 supervisees and Margaret as supervisor. We were conscious that many writers had suggested guidelines concerning the setting up of groups for the purpose of clinical supervision. Simms suggested that the group should ideally contain no more than seven people.(1) A larger group would not allow adequate time for the clinical supervision process to meet the needs of all members. As there was 8 of us who had completed the course it was agreed that we should divide equally into two groups bearing Simms recommendations in mind.(1)

In the groups we focused on the various aspects of 'Clinical supervision in practice' which was required before we went forward to offer clinical supervision to other members of staff. Group supervision was set up to deliberately mirror the guidelines and format that should be followed for individual sessions.

Five main issues were raised and explored.

To identify a suitable person

Due to Margaret Smith's experience she could comfortably supervise groups. However we considered ourselves fledgling supervisors and there was a consensus that initially we could only offer one-to-one supervision due to our inexperience.

The Supervisor should

1. Be available to staff.

2. Benefit the supervisee and the organisation.

3. Be affordable. Within our group it was felt important that clinical supervision should be carried out within working hours and staff should be released as necessary. Margaret Smith was employed on a locum basis at a very reasonable cost with the renal directorate meeting this expense.

Meeting Place

The venue was highlighted as an important issue. It has been suggested by Stoltenberg et al  that such a venue should facilitate the process and be away from interruptions  i.e.  telephones,  bleeps,  or anyone assuming the supervisee/supervisor is available. (2) In view of this, wherever possible all clinical supervision sessions take place away from the renal clinical environment. Punctuality of meetings was highlighted as essential.

Record maintenance

There are no clear guidelines as to whether records of sessions should be maintained or not. Within our group it was felt that both participants should make notes after each session as these would be helpful for summarising and for future evaluation.

Ground rules

1. Time keeping: not only is it important that participants arrive on time for the session, it should also finish promptly.

2. Confidentiality: anything discussed within clinical supervision sessions is to be confidential. Those in the relationship needed to trust one another, and feel that they are trusted.

3. Professionalism must be maintained at all times.

4. Commitment to attend e.g. requesting appropriate off duty.

5. No disruptions as discussed earlier.

6. Be non-judgmental: respect other peoples opinions and recognise that some people do things differently.

7. Both supervisor and supervisee are responsible for preparation of and contributing to the session.

Prior to the commencement of individual supervision sessions a general discussion took place as to what clinical supervision meant to the supervisor and how they would discuss this with the supervisee encouraging their comments and checking their knowledge. A general consensus in the group was that, broadly speaking, the main aims of clinical supervision could be divided into three areas as stated by Proctor,(3) these being:

• Formative; the educative process of developing skills.
• Restorative; supportive help for professionals working constantly with stress and distress.
• Normative; the managerial and quality control of professional practice.

In planning how individual sessions might be developed, the format for an agenda was discussed. Areas included were:

1.Working Relationships

This could be related to the clinical team, manager' mentors and the multidisciplinary team.

2.  Accountability

This included policy and procedure incorporating the UKCC code of professional conduct and administration and documentation.(4)

3.  Patient Care

What had been done well and what was problematic.

4.  Professional Development

Where the supervisee is at and what they want or need to do.

5.  Any other business

As can be seen the agenda was deliberately broad so that supervisors could develop their sessions with their supervisee without feeling constricted by narrow prescriptive guidelines.

Once comfortable with the clinical supervision process, and after selecting a supervisee, each member of the group commenced clinical supervision as discussed. This now continues with the original group beginning to develop skills in order to facilitate group supervision in the future.

All members of the two groups have demonstrated the ability to work together effectively led by Margaret Smith. Although originally we envisaged clinical supervision as an arena for discussing and reflecting on clinical situations, we quickly realised that this was not the way forward.  In order to establish clinical supervision within the Renal directorate our sessions have been a mirroring process, whereby we have been guided by Margaret, who has coached us in developing the necessary skills to feel confident to provide supervision. Our sessions with Margaret today revolve around  the  sessions with  our supervisees,  the difficulties encountered, the positive and negative aspects and discussion is currently taking place as to how we will evaluate clinical supervision.

Recently Linda Crofts, Director of Nursing Research and Development, was invited to a joint group session to investigate systems of evaluation. Overall it was decided that this was going to be difficult because of the complex and confidential nature of clinical supervision A S.W.O.T. analysis was suggested as a broad way of carrying out some form of evaluation. Since then we have brought this forward by the supervisor and supervisee completing a pie chart after each supervision session indicating the percentage of time used to cover formative, normative and restorative aspects of clinical supervision. This along with the S.W.O.T. analysis and the notes made from meetings will be the basis of our evaluations to be carried out immanently. Reviews of progress are built into the supervision process at regular intervals. These take place at individual and group level.

The process of developing clinical supervision has been stimulating and has introduced a much needed support system into the Renal directorate. There has been a drive to ensure that clinical supervision has commenced and continued to take place regularly from members of the nursing team keen to embrace this concept which although not new to many disciplines is a novel approach in nursing.

Acknowledements

We would like to thank Margaret Smith for her contributions and support in completing this article.

2. Stoltenberg CD, Delworth U. Supervising Counsellors and Therapists. San Francisco, Josey Bass 1987.

3. Proctor B. Supervision: A co-operative exercise in accountability. in Marken M, Payne M, eds. Enabling and Ensuring. Leicester: National Youth Bureau and Council for Education and Training in Youth and Community Work. 1986.

4. UKCC. Code of Conduct for Nurses, Midwives and Health Visitors. London: UKCC for Nurses, Midwives and Health Visitors. 1992.

Nursing Progress: Issue 2: July 1997.