What is supervision?
The word supervision is used a wide variety of senses. Most doctors and dentists use the term only in the context of formal training (eg in educational and clinical supervision for juniors). However, in other professions the term is used for a wider variety of conversations including case discussions between established clinicians. For example, in nursing it is understood as:
‘An exchange between practising professionals to enable the development of professional skills.’(Butterworth)
In our courses, we use the word supervision in this wider sense, to mean any focussed conversation between professionals about their work. The implication is that supervision is something that should happen throughout professional life, from student days to lifelong learning.
It is helpful to think of supervision in terms of two circles – development and performance. Sometimes supervision can be purely developmental and sometimes purely oriented towards performance. However in most supervision both are involved. Much depends on context ie who is asking for what to be done, who is reporting to whom and why. Although it is conventional to make a distinction between supervision, mentoring, coaching and career guidance but it practice many conversations will range between these.
What does supervision address?
Cases:
Most supervision takes place in order to address cases. These may be addressed in terms of technical management but often they raise broader issues, for example:
• when there is no one easy answer
• ethical issues
• complex cases
• ‘grey area’ cases: eg somatisation, frequent attenders, chronic fatigue, irritable bowel
• complaints, distressed families, angry patients, unlikeable patients
Contexts.
Cases never occur in a vacuum. Case management often depends on trying to achieve coherence among the professionals. Supervision may need to address:
• professional or interprofessional rivalries
• problems concerning communication
• teamwork issues
• roles and boundaries
• the differing expectations of patients and clinicians
• money, politics, gender, sexuality and power
Careers.
Case conversations quite often bring up issues about careers, for example:
• the need for further training
• work place conditions and job prospects
• longer term career aspirations
A narrative approach to supervision skills
There is evidence that skilled supervision sustains morale, increases job satisfaction, lessens stress, prevents burnout and dropout, and reduces complaints and litigation. Supervision skills are similar to good consultation skills and to effective team communication. All of these share the same micro-skills (hypothesising, open questions, empowerment) and model a reflective attitude (respect, thoughtfulness, seriousness, complexity).
People doing supervision use all sorts of approaches: informal chat, eclectic methods, approaches based on educational theory or counselling, psychodynamic ones etc. The approach taught in the London Deanery is a ‘narrative’ one: we have found that this approach makes sense to many clinicians and is easier to learn and teach than some other approaches.
A narrative approach to supervision does not reject other frameworks such as evidence based medicine, clinical science, psychodynamic understanding etc. What it offers instead is an overarching framework that allows people to value these as helpful contributions that can generate useful ways of looking at the world that may or not make a difference to someone’s story. It encourages us to see different discourses as sources of helpful hypotheses rather than absolute truths, and lets us move flexibly between these. A narrative approach encourages the exploration of ‘polyphony’ ie valuing the different stories that anyone is capable of telling about the same experience. Hence, agreed ‘truths’ are established by the process of dialogue itself.
There is a close connection between narrative ideas and systemic ones: ie the idea that we continually create our realities in conversation with people around us, and that families, societies and cultures are defined through their shared stories. In other words, our understanding of the world is always ‘dialogical’ in its origins and can be developed further through dialogue. We have spent the last decade at the Tavistock Clinic and London Deanery (now Health Education England) trying to make use of narrative and systemic ideas and skills for everyday consultations and supervision. We see our approach as one that completes the triangle between narrative studies, narrative approaches to therapy, and medicine.
Helen Halpern has formulated these in terms of the following ‘rules’ in relation to narrative-based supervision.
• The supervisor is not considered to be in a position of authority over the supervisee unless circumstances absolutely require this (eg concerns about performance). The supervisor’s role is to help the supervisee reflect and expand the narrative they present in a non-judgemental way.
• It is not necessarily expected that the conversation will lead directly to any solution but may simply help shift the dilemma or narrative in a more helpful way for the supervisee.
• The supervisor should not offer advice unless specifically requested by the supervisee.
• The conversation does not at first set out to explore the supervisee’s feelings, although their emotional response may become an important factor to consider.
• The supervisor asks questions rather than offering interpretations.
• Each question that is asked should be based on the response to the previous question.
• In general the supervisor should not ask a question if they think that both they and the supervisee already know the answer.
• The supervisor needs to pay close attention to the language used by the supervisee and to track this and its meaning.
• The supervisor notes non-verbal cues and body language and uses this to help frame subsequent questions.
• The supervisor will necessarily base their questions on their own knowledge and experience but needs to be wary of making assumptions and imposing these on the supervisee. Indeed one of their roles may be to challenge the supervisee’s assumptions.
References
Burton J and Launer J (eds) Supervision and Support in Primary Care. Abingdon, Radcliffe, 2003.
Launer J. New Stories For Old: Narrative-based primary care in Great Britain. Families, Systems and Health 2006; 24: 379-389
Launer
J. Supervision, mentoring and coaching. In T. Swanwick, (ed.),
Understanding medical education: evidence, theory and practice, 2nd
edition. London, UK: Wiley-Blackwell, 2013.
Launer J and Halpern
H. Reflective Practice and Clinical Supervision: an approach to
promoting clinical supervision among general practitioners. Work Based
Learning in Primary Care 2006;4:69-72