The Introduction of Clinical Supervision within a PCT

Clinical supervision has been integral to practice in social work, mental health, psychotherapy, midwifery for many years. More recently there has been recognition of the benefits of clinical supervision by nursing and allied professionals as a method of facilitating learning by practitioners from practice.

Clinical supervision forms an important part of meeting Healthcare Commission Standards for Better Health and Clinical Governance requirements. (DOH, 2000, Health Care Commission 2006/2007, Skills for Health, 2007)

In a publicly funded Health Service the public has the right to expect that practioners will provide care that is consistent with what is known to be good practice.

The first part of the essay will examine Leadership and Management concepts, models and theories the second part I will discuss what change models and leadership theories could be used to introduce clinical supervision to the staff of a PCT .

Leadership has been the subject of numerous studies in the latter half of the twentieth

century. However there is still no single clear and consistent definition of leadership or its characteristics. Bass (1990) noted that there appear to be as many definitions as there are researchers of the topic.

To understand the evolution of leadership, we need to look at how leadership theories have developed over the years.

The Great Man Theory explains that leaders are born, not made, and will arise when a great need arises. The theory was based on studies of great leaders who usually came from the aristocracy and were male (Bolden et al 2003). You either have those leadership qualities in you or not. Only those men who are blessed with leadership qualities can ever emerge as leaders. Great leaders cannot be created; they arise whenever there is a need for them. A follower of this theory would be likely to study the Second World War, by studying the conflict between the big personalities such as Adolf Hitler and Winston Churchill etc. This theory lasted until the 1940s, as it did not take into account the human ability to think, learn and innovate.

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The scientific study of traits required for excelling in the field of leadership started at the turn of the 20th century. This theory emphasizes on the importance of being inherited with leadership skills and choosing the right person for being a leader. Although there are certain traits that are required to be a good leader, in this case there is an over-emphasis on required traits. The list of traits of successful leaders is never ending and it is not essential to have similar traits for excelling.

The trait theory was thrown into confusion mid-century when early reviewers of leadership research came to the conclusion that there is no clear tie between a leaders traits and effective leadership (Lord, De Vader and Alliger 1986). This gave way to behavioural Theories in the 1950s. There were two major researches that were conducted. In the first study the focus was on the behaviour of leaders and how they treated their followers, is it auto-cratic or democratic or is it Laissez-Faire that is followed. This theory also emphasized on training people for leadership, i.e.: influencing their behaviour. The second theory had two parts, the first part treated workers in a harsh way, the workers were thought to be lazy and stubborn, and they had poor working habits and were only motivated by money. The workers were to be given instructions and be controlled properly so that they did not get out of hand and they knew all the time who was boss. The second part of this theory was politer, it took workers as human beings who worked hard, were very cooperative and had a positive approach towards work. Both these theories have worked successfully over the period of time. But this theory gave a very one sided view of things and did not explain properly the problems of leadership. Both the parts of this theory were two extremes, so you do not get a proper idea on what path to follow.

The contingency theory Fielder (1967) explains that the leader’s ability to lead is dependent upon various situational factors, including the leader’s favoured style, the capabilities and behaviours of followers and various other situational factors. These theories also emphasize on the fact that there is no one best way of leading and that a leadership style that is effective in some situations may not be successful in others. This is explained by the saying “Great war time leaders are normally worst time peace leaders”. This explains how leaders who at times act like master of all trades and seem to possess the ‘Midas touch’ suddenly appear to go off the boil and make very ineffective decisions.

Hersey and Blanchards Situational Theory Hersey P & Blanchard K H (1999) suggest a leader should adjust his/her style according to the follower’s eagerness so that everyone can take responsibility for directing their own actions. It is like a democratic approach where everybody has their say. This approach asks managers to be flexible and vary their style. This approach is more useful as employees gain more aptitude, skills, self belief and confidence. The major problem with this approach is it takes managers as very caring and flexible, which is not always the case in the real world. A lot of trust is being shown in the analytical abilities of managers, which can go wrong and lead to problems.

The concept of leadership in nursing can be traced back to Florence Nightingale. In the late nineteenth century she exercised power autocratically and promoted her model of leadership through the role of matron. She called her nurse managers ‘specials’, and until the 1960s they were similar to their military counterparts.

In the middle of the 1980s nursing re-examined leadership in the profession and the apparent lack of it. This led, by the end of that decade, to the publication of a Strategy for Nursing (DoH 1989), which defined leadership as ‘setting the pace and direction for change, facilitating innovative practice, ensuring that policy is up to date, that professional standards are set in relation to care and that a comprehensive service is developed over time’.

Up until the late 1980s there was a lack of research into nursing leadership in the UK. Since then most of the literature has been anecdotal with few experimental studies. Much of the research into leadership took place in the US. Bass (1990) found 7,500 research studies, papers and monographs on the subject of leadership.

A study published in the Harvard Business Review, (1988) which was conducted in a US public sector organization, found that the most important feature of effective management is not skill but attitude towards staff ( Livingstone 1988). The researcher found that that, unfortunately, managers often unintentionally communicate low expectations. In doing so they become ‘negative Pygmalion’s’ who undermine the self confidence of their staff and reduce their effectiveness. Wright (1996) noted that ideas on leadership have arisen from sociological studies and commentary from political and industrial sources. He also believes that those are not the most suitable sources for nursing.

There are a number of useful models to help to guide senior nurses in leading other staff. The two most common are transformational and transactional models Bass, (1985), Burns (1978).

The core of transactional leadership lies in the notion that the leader, who holds power and control over his or her employees or followers, provides incentives for followers to do what the leader wants, Hence, the notion that if an employee does what is desired, a reward will follow, and if an employee does not, a punishment or with holding of the reward will occur.

The relationship between leader and employee becomes ‘transactional’; I will give you this if you will give me that, where the leader controls the rewards, or contingencies.

In addition to contingent rewards, transactional leaders are said to ‘manage by exception’ which refers to the idea that they are less interested in changing, or transforming the work environment or employees, but seek to keep everything constant except where problems occur (e.g. lack of goal attainment)

While common, transactional leadership relies on a set of assumptions about human beings and what motivates them. This form of leadership would have a place where there is a specific short term directed project or piece of work to be completed, and can also be used when targets for clinical governance need to be met. With targets needing to be met, audits needing to be done, this form of leadership I believe has a place when staff need direction and a time limit to complete certain tasks or paperwork.

In nursing it is more desirable to identify a leadership model that offers longevity in the relationship between senior and junior nurses. The transformational model is more complex but has a more positive effect on communication and teambuilding than the transactional model (Thyer 2003). Transformational leadership shapes and alters the goals and values of other staff to achieve a collective purpose to benefit the nursing profession and the employing organization. Bass (1985) found that transformational leadership factors were more highly correlated with perceived group effectiveness and job satisfaction, and contributed more to individual performance and motivation, than transactional leaders. Transformational leadership can protect against the adverse affects of stress as transformational leadership behaviours are associated with a multiplicity of positive work attitudes amongst staff (Stordeur et al. 2000). This would suggest that transformational leadership has a cascading effect. Bass et al (1987) report that when transformational leadership behaviours were practiced at the top level of the organizations, this leadership style was mirrored downwards through the organizational ladder. Similar studies McDaniel and Wolf (1992) concur with Bass et al (1987) premise that like the falling dominoes effect, transformational leadership is expected to influence staff at all levels below. Transformational leadership is not a substitute for transactional leadership; conversely it compliments, develops and enhances it ( Stordeur et al 2001). However, unlike transactional leaders, transformational leaders motivate and energize staff to pursue mutual goals, share visions and ensconce an empowering culture, where personal values and reciprocated respect are fundamental principles.

The PCT I work within has had many changes of senior managers, and the organization is continually going through change. Senior managers are viewed as being autocratic and transactional. This has led to a feeling of disempowerment.

Finegan and Spence Laschinger (2001) highlight that disempowerment transpires when individuals are deprived of opportunities for growth and development. They are excluded from the decision making process and frequently lack resources to do their job effectively whilst still responsible and accountable for their action. Hence, these nurses feel frustrated, incompetent and have little loyalty to their organization. This implicates on the effectiveness of organizational goals, but more importantly disempowerment can manifest in disinterest and apathy which subsequently influences patient care (Clegg 2001). Furthermore, insufficient staffing levels contribute to emotional exhaustion and fatigue as a result of unrelenting attempts to deliver a quality service under enormous pressures and stressors (Clegg 2001). Dunham-Taylor (2000) contends that in this turbulent health care environment, nurse managers can inadvertently become so involved in the day-to-day crises that staff empowerment does not take precedence.

As a relatively new team leader I am aware of staff’s feelings towards the organization, and am attempting to help staff feel more empowered.

Using transformational leadership I facilitate increased opportunities for staff participation and decision making within our team and ensure a two way communication process is open. Transformational leaders invite, listen and value the opinions of all staff, which decreases interpersonal conflict and non-cooperative relationships. (Stordeur et al 2001).

So for making an organization perform at an optimum level, you need to have an encouraging friendly environment in which everyone gets a chance to display their skills.

As argued by Druker (1995) “The leaders who work most effectively, it seems to me, never say I, and that is not because they have trained themselves not to say I. They do not think I. They think we’; they think team’ They understand their job to be to make the team function. They accept responsibility and do not sidestep it, but we’ gets the credit. This is what creates trust, what enables you to get the task done. This means a leader should act like a mentor, a nurturer for co-workers. In this way best performance can be achieved which is what is desired.”

Change is nothing new and indeed has been our only constant, but change today is faster and more complex than it has ever been before (Manion 1994). Change is an essential part of life, however in essence it is only likely to be welcomed if it is perceived as being necessary, rather than inevitable.

Change theory originated from Karl Lewin in 1951. His model of change is one of the most widely promoted models. Lewin introduced the concepts of driving and restraining forces that either help or restrain the change process( Lancaster and Lancaster 1982). He describes driving forces as those that facilitate change, by electing a change agent and moving the group with this agent. Restraining forces are those who slow the change process or stop the change from taking place. Change occurs when one force outweighs the other. Lewin states that it is important to know the driving and restraining forces in order to deal with the restraints.

There are numerous theories that explain how and why change occurs but Lewin (1951) identified three stages to change, unfreezing, moving, and refreezing. Therefore for change to occur, the current state must be ‘unfrozen’ by people becoming aware of the problem and the necessity for change. Then the forces holding the change in equilibrium must be worked on by increasing the forces driving the change and minimizing those resisting it. Finally everything must be ‘refrozen’ with the change integrated into the person, the organization and the culture.

Another model of change proposed by Post (1989) suggests that change has five phases; preparation, movement, synergy, the new reality and integration. The preparation phase involves defining the purpose of the change, and identifying resources to implement it. The second phase of movement involves devising a plan. For example, identifying a plan of action, which highlights the process for implementing the change. The third phase, synergy, involves coordination and cooperation, which includes using interpersonal skills, for example employing suitable leadership styles and effective communication skills. The fourth phase, new reality would refer to introducing methods to ensure that the change is maintained, and regular monitoring of the change would be implemented. Finally the integration phase highlights quality issues related to the change, ensuring consistent quality standards and highlighting the need for evaluation. McPhail (1997) states that if nurses follow the phases proposed by Post then the effectiveness of the nurse as a change agent is greatly enhanced.

However a number of other models derived from sociological research attempt to explain events as the process of change unfolds. Stocking (1992) in her article ‘Managing the human side of change’ discusses promoting change in clinical care and the social interaction model based on the work of Rogers and Shoemaker (1971). This model describes the process involved when an innovation is communicated to members of a social system. Rogers and Shoemaker (1971) proposed that four factors influenced whether changes were accepted and incorporated into practice. Firstly the advantage of a new practice and how it can improve on existing practices. Secondly, how compatible the change is with the present practices and staff attitudes. Thirdly, the complexity of the innovation, the feasibility for easily understanding and implementing it and finally, the possibility that the innovation can be realistically tried out, are more likely to be adopted than changes that do not demonstrate these characteristics.

Wright (1993) states that a change agent might be a person who has his or hers own ideas about what needs to be changed, who can marshal the arguments, keep up the pressure and often carry things forward using charisma, passion and enthusiasm. The change agent is described as a ‘catalytic protagonist of the change process’ Broskowski et al (1975). It is the role of the change agent to generate ideas, introduce ideas, introduce innovations, develop a climate for planned change by overcoming resistance and implement and evaluate change (Lancaster and Lancaster 1982). A successful change agent needs to be able to formulate goals amongst colleagues, be able to motivate others, solve problems and make decisions, communicate effectively and be assertive although remain sensitive to the needs of others (Wright 1993).

According to Lancaster and Lancaster (1982) there are two types of change agent, external and internal. The external change agent can often see the situation more clearly; this is because they can be an outsider or stranger to the group. This could however be a disadvantage, as the group may not welcome a stranger and it would take longer for the group to learn to trust them. Whereas the internal agent has the advantage of knowing the group and the system. In order to implement successful change to practice. Mauksch and Miller (1981) identify that the status of the individual who suggests new ideas seems to have great bearing on the manner in which new ideas will be accepted. As the team leader I would be recognized as an internal change agent, as I know my colleagues and am trusted by them.

As discussed various theories attempt to describe how the change process actually develops. Some models describe change in a theoretical way, while other models refer to a framework for practical action.( Egan 1985). In the top down approach, decisions are taken unilaterally by top management without consultation. Although it may initially appear that change is underway, the motivation to continue the change is lost due to lack of commitment from those who should have been consulted in the first place.

In comparison the bottom up approach tends to be based on rationality and logic. It is based on ideas of leadership and change agents who drive the change from the ‘shop floor’. It has been conceptualized as being participative. It mirrors some of the characteristics of organic organizations, namely the consensus about decisions, solutions that are sought jointly, high participation, high dependence on the group and the sharing of satisfaction among the group (Plant 1987). The normative re-educative approach is where change also originates from the bottom upwards. This looks at the fact that people can achieve the best results by acting collectively. It suggests that due to the way the group owns the change by following this approach, it is more likely to be accepted and the change sustained.

In order to implement change, Hoffer (1986) suggests that the chosen strategy must be matched to the people involved, while Wright (1986) supports that effective change is not only dependent on the selection of appropriate frameworks for practice, but also on the active involvement of participants. Stokes (1994) argues that professionals can have difficulty working out a coherent and shared purpose in practice as they have had different training which has given them different values, priorities and preoccupations.

For change to take place, it would help if the people concerned were motivated to change. There are many theories of motivation; I will discuss a few of the most common theories.

A motive is what prompts a person to act in a certain way or at least develop an inclination for specific behaviour Kast and Rosenzweig (1985). “Motivation” can be defined as those forces within an individual that push or propel him to satisfy basic needs or wants (Yorks 1976). Maslow also states that “Only unsatisfied needs provide the sources of motivation; a satisfied need creates no tension and therefore no motivation”. Burke (1987). Motivators are the factors that arouse, direct and sustain increased performance( Duttweiler 1986).

Abraham Maslow believed that man is inherently good and argued that individuals possess a constantly growing inner drive that has great potential. The needs hierarchy system, devised by Maslow (1954), is a commonly used scheme for classifying human motives. Maslow suggested five basic needs that we all uphold. These are physiological, safety, social, esteem, and self-actualisation. Physiological needs are for instance, food, drink, shelter, sex, and other bodily requirements. Safety needs deal with the security and protection from physical and emotional harm. Social needs refer to affection and belonging needs. That means an individual will want good relationships with people and a place in his/her group. Therefore extra attention will be given to friends, husband and children etc. Also all the individuals have a need for a stable and high regard of themselves, and self esteem and respect from others. Esteem needs may be categorized as internal and external factors. Internal esteem factors such as self respect, autonomy and achievement, and external esteem factors such as status, recognition and attention.

Maslow’s hierarchy of needs could be applied to work situations. Certain needs need to be met, physiological needs, the need for a safe and pleasant work environment. Safety needs, the need for an acceptable wage, pension, and job security. Social needs, the need to interact with colleagues and feel part of the organisation. Self esteem needs, the need for a career path and achievement, for feedback and recognition of good performance. Self actualization would be when you had reached where you want to be in the organisation and are committed to your job.

Hertzberg’s motivation-hygiene theory (1959) is often called the two factor theory and focuses on the sources of motivation which are pertinent to the accomplishment of work (Hall and Williams 1986) Herzberg concluded that job satisfaction and dissatisfaction were the products of two separate factors, hygiene factors and motivators. Hygiene factors (dissatisfiers) are, company policy, supervision, working conditions, interpersonal relationships, salary, status, job security and personal life. Motivators (satisfiers) are achievement, recognition, work itself, responsibility, advancement and growth. Herzberg reasoned that because the factors causing satisfaction are different from those causing dissatisfaction, the two feelings cannot be simply treated as opposites of each other. The opposite of satisfaction is not dissatisfaction, but rather, no satisfaction. Similarly the opposite of dissatisfaction is no dissatisfaction. This theory would suggest that management must provide hygiene factors to avoid employee dissatisfaction, but must also provide factors intrinsic to the work itself in order for employees to be satisfied with their jobs. Critics of Herzberg’s theory argue that the two factor result is observed because it is natural for people to take credit for satisfaction and to blame dissatisfaction on external factors. Furthermore, job satisfaction does not necessarily imply a high level of motivation or productivity.

McClelland’s Need For Achievement Theory (1961) proposed a theory of motivation that is closely related with learning concepts. The theory proposes that when a need is strong in a person, its effect is to motivate the person to use behaviour which leads to satisfaction of the need. The main theme of McClelland’s theory is that needs are learned through coping with one’s environment. Since needs are learned, behaviour which is rewarded tends to occur at a higher frequency. McClelland developed a descriptive set of factors which reflect a high need for achievement. These are; 1) The need for achievement is characterized by the wish to take responsibility for finding solutions to problems, master complex tasks, set goals, get feedback on their level of success. 2) The need for affiliation is characterized by the desire to belong, an enjoyment of teamwork, a concern about interpersonal relationships, and a need to reduce uncertainty. 3) The need for power is characterized by a drive to control and influence others, a need to win arguments, a need to persuade and prevail.

Adults are presumed to possess al three motivations to one degree or another, however one is usually dominant. Managers need to identify what motivates others, and to create motivating conditions for them.

To achieve clinical effectiveness the government has introduced a framework of Clinical Governance. ‘The New NHS Modern Dependable’ DoH (1997) and ‘A First Class Service: Quality in The New NHS DoH (1998), there is an emphasis on improving quality of care, treatment and services through employing the principles of clinical governance. Clinical governance gives the NHS as a whole and trusts at local level, responsibility to ensure quality of care, consistent standards of quality of care. One of the main driving forces behind clinical supervision was ‘Clinical supervision. A position paper’, by Faugier and Butterworth (1993). It stressed how valuable clinical supervision was for the development of professional expertise and delivery of quality of care. This was quickly followed by the Vision for the Future Document (Department of Health 1993) which stated that, ‘the concept of clinical supervision should be further explored and developed’. The UKCC Position Statement on Clinical Supervision (UKCC 1996) for Nursing and Health Visiting also endorsed the establishment of clinical supervision, in the interests of maintaining and improving standards of care.

The demands on nurses to be competent, developing new skills and constantly updating their knowledge and be accountable for their actions were highlighted in the UKCC guidelines for professional accountability UKCC (1992). Clinical supervision is just one component of clinical governance that facilitates staff to practice safely and efficiently. As defined by the DoH (1993) clinical supervision is ‘a formal process of professional support and learning which enables individual parishioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations’. Clinical supervision has been adopted widely across NHS Trusts.

The framework of clinical supervision provides NHS staff with the chance to reflect on their practice identify weaknesses and build on strengths, and with the confidence gained to promote quality patient care contributing to the development of others (Bishop 1998). Clinical supervision is a mechanism to empower staff to practice safely, confidently with the motivation to strive for clinical excellence, it is however not a cheap option and requires considerable investment and time (Bishop 1998).

The decision to implement clinical supervision required a major change in practice and culture for the staff in the PCT. The leadership of change requires ‘vision, courage, creativity, effective communication and a clear plan’ as identified by (Daly et al 2004).

Marquis and Houston (2002) describe planned change as ‘a well thought out and deliberate effort to make something happen’.

Strong transformational leadership that balances outcomes, stakeholder’s interests, and emotions in a positive fashion, with the ongoing management of operational requirements is essential life a genuine change in policy is to be achieved (Cameron and Green 2003).

This would indicate that if as a team leader showed that I was approaching the implementation of Clinical supervision using the essence of transformational leadership , as the focus of this type of leadership is the promotion of innovation and change Carroll (2006), then it would be more likely to be accepted by the team.

There are many change theories, and they all ask, how does successful change happen.

Kurt Lewin (1951) introduced the three-step change model. This is the model I used to enable clinical supervision to be become part of staff’s normal working practice. The basic idea is to ‘unfreeze’ current methods, so that new ideas and implemented changes can be fixated and put into place, and then to ‘freeze’ these new procedures so that they will stick, and those affected by them can learn and become accustomed to the new process involving their work (Rouda 1995)

Driving forces facilitate change because they push employees in the right direction. Restraining forces hinder change because they push employees in the opposite direction. Therefore these forces must be analysed and Lewin’s three -step model can help shift the balance in the direction of the planned change.

According to Lewin the first step in the process of changing behaviour is to unfreeze the existing situation or status quo. Unfreezing is necessary to overcome the strains of individual resistance and group conformity. Some activities that that can assist in the unfreezing step include: motivating participants by preparing them for change, build trust and recognition for the need to change, and actively participate in recognizing problems and brainstorming solutions within a group. (Robbins 2003)

I would need to identify what was needed to get staff ready for change in the ‘unfreezing’ stage. Firstly, the necessity for change and the nature of change needed. Meetings with staff need to be arranged to talk to staff and explain what clinical supervision is and raise awareness among all staff, because the term clinical supervision is often ‘misconceived’ by nurses Butterworth and Faugier (1994). I needed to convey what will be achieved by the change, particularly the benefits to the patients. Muller (1994) suggests that if we approach change in a positive light, we could see it as a way to make the lives of our patient’s better, which in turn should encourage active involvement from participant. However if the participants/staff disagree with the change, the process becomes difficult. Resistance and reluctance and the accompanying heightened emotions, tension and stress have been implicated as factors, which hinder the change process. Smith (1996) stresses that a more holistic approach, which confronts the fears and concerns of the staff and draws them with the change process, is what the human side of change is all about. If there are highly motivated staff within the team this could be seen as a driving force towards the implementation of clinical supervision. One of the resisting forces could be the lack of knowledge of clinical supervision. Deegan (2004) highlights the collaborative process as vital when implementing change; teams must share a vision for the future. To help staff with this I gathered information together and disseminated it to staff at our team meeting, I also reassured them that clinical supervision would not go ahead without adequate training. There was little understanding of it amongst staff, and certainly it was an area I didn’t have much knowledge of myself until I sought out information and spoke to colleagues from other disciplines to educate myself. According to Bartle (2000)’ Successful implementation of clinical supervision will depend on staffs understanding of what clinical supervision is’.