Veronica Bishop

Clinical supervision: What is going on? Results of a questionnaire

This paper presents data obtained from a questionnaire sent to trust nurse executives in England and Scotland. White the data indicate a great deal of enthusiasm for clinical supervision, some concern must be shown for the lack of preparation and support for those involved in its implementation, a fact which will undoubtedly reflect badly in any evaluation exercise.

Clinical governance and clinical supervision: protecting standards of care

The government document A First Class Service – Quality in the New NHS (Department of Health, 1998) stated that one of the key strategies for achieving quality was the introduction of clinical governance, and as Scott noted (above) this would require a fundamental change in culture. Sadly, while there has been a significant change in culture it has had little to do with quality, as recent media coverage in the South of England, and numerous anecdotes testify. It is important to remember, when despairing over such displays of the most blatant abrogation of standards, that there are people doing fine work in the NHS, but it is also important to scrutinise carefully that which has put management and nursing in a very bad light, and to consider how this might have been avoided. What are the lessons to be learned? One wonders why qualified nurses with an accountability to both their profession and to the State struggle on when conditions for patients are so appalling? A misguided notion of not letting people down? A fear of whistle-blowing? Whatever the reasons – and no doubt they are as varied as the staff involved – the highly exposed weakness of nursing need to be examined. It is highly relevant to note that in the recent White Paper (Secretary of State for Health, 2007) proposals are made to strengthen continuing professional development, amongst other measures aimed at improving performance in general, as well as eliminating poor performance more effectively than in the past.These proposals must be welcomed and concur with the views of Scott (1999: 173) who stated that for clinical governance to be successful:

Capacity-building and careers in nursing research: Rationale and context

This paper aims to review and provide a brief critique of the modern health service in the UK, highlighting the need for nursing to develop a genuine culture of research that can enable the profession to deliver research-oriented practice. The need to develop careers in nursing in order to provide evidence-based practice and appropriate care to patients is discussed within the context of current policy drives and professional aspirations. It is argued that not only will this raise the overall standard of care, but also will develop the level of professional knowledge, credibility and accountability of practitioners. Links between research, clinical governance and evidence-based practice are made, and the wider implications for the position of nursing within healthcare services are discussed.

The policy–practice divide

This study on clinical supervision, from an academic unit with a proven track record of longitudinal studies (e.g. Marsland and Murrells, 2000) reports on the experiences of 1,918 diplomate nurses in their early career, 18 months after qualification from the adult, child, learning disability and mental health branches. It is perhaps the largest study to date on this subject, and while it has its limitations, in that clinical supervision was just one aspect of the study that explored nurses’ career pathways and aspirations (thus restricting the number of questions that could be included in the questionnaire about clinical supervision), it delivers some very important messages. The findings from this study are as relevant now as they were in the 1990s, when clinical supervision became central to the UK nursing strategy, with the approval of professional nursing organisations and trust nurse executives (Butterworth and Bishop, 1994). The issues of organisational instability, fast turnover of patients and increased workload that created a real need to nurture and develop a highly competent nursing workforce have not changed, nor are they likely to. Added to these factors, the importance of clinical governance and the relevance of clinical supervision should not be underestimated; clinical supervision offers a framework for public safely and clinical excellence. Normand (2004) noted that within the concept of clinical governance there are always conflicting interests. The nursing profession needs to identify, unapologetically, its unique contribution to healthcare, and clinical supervision is the ideal framework for that. Properly conducted, it will ensure that standards are maintained, that interventions are appropriate, and that despite a frenetic pace of work, individual nurses can function therapeutically, rather than become mini-bureaucrats distanced from the humanity of care. Findings in this study showed that just over half the learning disability and mental health diplomates were receiving clinical supervision compared with approximately one-third of those graduating from the adult and child branches. While the majority of nurses questioned considered that their needs were met in terms of assistance with setting learning objectives, and discussing incidents that occurred at work, over onequarter of supervisees in each branch wanted more discussion of such incidents. Of particular concern is that many wanted more supervision in relation to new clinical skills, professional practice and with reflection on practice. Overall, it is discouraging to find that, early in their careers, only slightly more than one-third of the cohort had a supervisor from whom they were receiving clinical supervision, and that just over one-third had never had a supervisor in their current job. The findings provide the basis for a national picture of how clinical supervision has been implemented in nursing, and highlights the relatively poor availability of supervision in the adult and child branches compared with the learning disability and mental health branches.

Clinical governance and nursing power

JRN is committed to disseminating and supporting high-quality care whether through policy or through academic endeavour. We are not unique in the aim; it is the stated intention of almost all organisations, journals, and fora involved in health care. However, the reality is often found to fall short of the intention. The introduction of clinical governance (Scally and Donaldson, 1998) in the United Kingdom should have heralded a new approach to quality, as was noted by Scott (2002 p. 38) who stated. ‘considering the focus in healthcare in recent years has been on the financial agenda and managerial framework, we are presented with a challenge that demands a radical change in thinking, which will in essence require a fundamental change in culture’. This culture change is still to occur, and the opportunities integral to clinical governance are not being realised in the current narrowness of its interpretation. Clinical governance is primarily concerned with standards and with the dissemination of best evidence. The term ‘governance’ aims to ensure accountability and excellence in the corporate and the financial management of the National Health Service (NHS) by focusing control locally. Clinical governance is an extension of financial governance to clinical practices, and the need for organisations to provide effective, quality health care has been the subject of a number of policy and strategy documents in the United Kingdom within both the NHS and the independent sector. Several national and international initiatives have been developed to facilitate clinical governance, which focus on implementation of evidence-based practice, including the establishment in the United Kingdom of the National Institute for Clinical Effectiveness. The government document A First Class Service – quality in the New NHS (DOH, 1998) stated that one of the key strategies for achieving quality was the introduction of clinical governance. The most important principle of clinical governance is a commitment to high quality, safe, patient-centred services in clinical practice, which JRN highlighted in the Focus of the earlier issue, describing some of the excellent work in this area (JRN 14,4). Models used in clinical governance tend to have emerged from the work of a late chief medical officer and a regional public health director (Scally and Donaldson, 1998), which work well for care interventions that are clearly defined and measurable, but are less sensitive to many of the interventions and interactions carried out by nurses. Further initiatives in the United Kingdom have sought to bridge the gap between clinical outcomes and patient satisfaction. As McClarey Journal of Research in Nursing ©2009 SAGE PUBLICATIONS Los Angeles, London, New Delhi and Singapore VOL 14 (5) 387–389 DOI: 10.1177/ 1744987109106952 E D I TOR I A L

Health care research in context: Global influences and individual aspirations

As papers in this special issue indicate, nursing across the globe has taken major steps in reaching across geographical boundaries in order to share ideas, to strengthen strategies through collaboration and to take its rightful place at the centre of health care. We are at a place that has not easily been reached—outdated traditions, differing views, well-developed hierarchies all have to be navigated with care. Those involved in such work across the globe are to be applauded. At the 54th World Health Assembly held in 2001, member states were urged to strengthen nursing and midwifery through strategies that included closer involvement of these two professions in health policy, stressing that they had a pivotal role in health care initiatives. While significant progress had been noted in the development of strategies for these professions, there was at that time a serious shortfall of training fellowships when compared with demand. In the intervening 8 years, much progress has been made in terms of opportunities for individuals wishing to further their professional development and their understanding of their discipline. The term ‘research’ is now used in common parlance, not just confined to ivory towers! But we still have a long way to go. It has been noted elsewhere (Bishop and Freshwater, 2004) that the development of new roles to meet new challenges is gathering momentum. It is clear that with the increase of specialisms, changing demographics and ever increasing demands from health services, new methods of effective working have to be tried and tested and the role of professionals in all health care disciplines questioned. If nurses and others are to maximise their role and be crucial participants in the future development and design of health care, then educational institutions across the world have a responsibility to prepare them for international leadership positions. Academia in the allied health professionals has been a piecemeal business, with nursing having the longest history and, thus, more time to organise its educational requirements, an exercise that is still ongoing and, given the dynamics of society, is likely to remain so (Bishop, 2009). McKenna and Galvin (2004) concur with Lanara (1994) in considering that members of any profession are best able to appreciate the essence of their discipline when their educational programme includes not only studying but also generating, challenging and testing the knowledge in their field, and they make a strong case for the scholarly practitioner with doctoral qualifications. They note that Journal of Research in Nursing ©2009 SAGE PUBLICATIONS Los Angeles, London, New Delhi and Singapore VOL 14 (2) 99–101 DOI: 10.1177/ 1744987108102008 E D I TOR I A L

A qualitative study exploring practice nurses’ experience of participating in a primary care–based randomised controlled trial

This paper describes a small qualitative study that explored selected practice nurses’ experiences in participating in a multi-centred randomised control trial designed to promote compliance and increase self-efficacy for people with type 2 diabetes. As a one-time clinical researcher, who approached patients to obtain for consent to take part in invasive and non-invasive studies, this small study brought back to me many of the issues that arise when seeking goodwill of patients, even it is in the longer term, it is for their benefit. The work described here would have been more valuable if the ethical issues that arise from such work were discussed more fully, rather than a mere reference to the Local Research Ethics Committee award number. However, the insights gained deserve attention as they echo what one hears anecdotally, and which need addressing in future strategies that involve research in the community. It is interesting to note that 40 general practitioner surgeries initially agreed to take part in the main study, with payment offered to offset expenses, which led to an anticipated recruitment of 375 participants. However, with only 29 practices successfully recruiting participants for the study one wonders why? Certainly, it was a lost opportunity for this particular study of staff involvement and attitudes. Those practices that accepted the financial incentives do not appear to have met their side of the bargain – allocating time, another ethical consideration in the entire process. Of the data that are given my greatest concern is the well described ‘gatekeeper role’ that the researchers here identified. In as much as the researchers purposefully selected nurses who were motivated to be involved, so did all but three of these nurses purposefully select their patients. The data suggest that the reasons for poor recruitment were mainly because of shortage of time rather than lack of staff interest. Given that the GP practices involved were being paid a fee for each patient recruited, one might have expected a more lenient timetable for the nurses involved. Possibly, a more precise arrangement should be written into the research protocol to avoid this in future studies. The fact that nurses who worked in ‘research active’ practices showed a higher rate of recruitment and actively looked to move their practice on is encouraging and would support the notion of strengthening the research capacity in Journal of Research in Nursing ©2009 SAGE PUBLICATIONS Los Angeles, London, New Delhi and Singapore VOL 14 (5) 449–450 DOI: 10.1177/ 1744987108098229 R E V I EW

A commission into nursing; an insular exercise or a welcome opportunity?:

Participating in the 50th Royal College of Nursing Research Society conference was bound to be significant. JRN, in collaboration with the National Health Service Institute for Innovation and Improvement hosted a particularly well-attended debate on ‘This house believes that the Professional Doctorate is of equal standing to a PhD by research and contests recent policy agendas which imply this is not the case’. The proceedings will be published in the next issue of this journal. JRN also supported the Akinsanya Award 2009 for Innovation in Doctoral Scholarship in Nursing, won this year by Dr Patrice Van Cleemput. The winning project – Gypsies and travellers accessing primary health care: interactions with health staff and requirements for ‘culturally safe’ services – explores the barriers that prevent travelling communities in England from accessing health care services. Despite the global credit crunch, the 450 attendees at the conference who came from Wales, England, Scotland, Ireland (north and south), China, Australia, Canada, USA, Spain, Portugal and Israel were offered an immense range of topics, and as a member of the scientific review panel for the past 10 years, I can say that the standard of entries was exceptionally high. All this puts nursing very much to the fore for more positive reasons than is often the case, not least as a completely unheralded new commission into nursing (it is not clear if this is just for England or for the entire UK, which in itself is interesting) was launched on March 10 this year. Sponsored by the Prime Minister’s Office, the commission will be chaired by a minister with a nursing background, Ann Keen. This has been set up with scant involvement of senior members of the profession, to advise the government on the future role of nurses and midwives. Indeed, one could question as to whether this is a commission on nursing solely in London, such is its membership, rather than for the country as a whole. It is also hard to see how this commission will inter-connect with the stumbling advances of the ‘Modernising Nursing Careers’ programme, whose only success, so far, has been the clinical academic careers element initially driven by the United Kingdom Clinical Research Collaborative (UKCRC). That with ministerial support we should look to build on existing work identified in Lord Darzi’s report High Quality Care for All is encouraging. But qualified nurses know how they can further improve safety and champion high-quality patient care. They also know that this is not achieved through commissions, rather by sensible staffing levels, as studies from the past two decades have highlighted (e.g., Carr-Hill, et al., 1992; Buchan, 2002, 2004) and the Journal of Research in Nursing ©2009 SAGE PUBLICATIONS Los Angeles, London, New Delhi and Singapore VOL 14 (3) 195–197 DOI: 10.1177/ 1744987109105806 E D I TOR I A L

Review: Using art-based techniques in engaging children and young people in health care consultations and/or research

Art – the conscious arrangement or production of sounds, colours, forms, words, movements or other elements in a manner that affects not just a sense of beauty but a recognition of what, indeed, may not be beautiful, but very meaningful. The use of music in health care has been noted in ancient scripts, not least in the Bible and far more recently in JRN by Batt-Rawden (2007) with an excellent review by Jones. Other forms such as the use of dance and painting have been used similarly. Art, in the pictorial sense, is potentially a powerful medium through which people and, more specifically for the purposes of this paper, children can express themselves. The use of art in research, whether by using paper and crayon or digital camera, is not new. Indeed, a useful brief history is given at the outset of the paper. Added to this are two further examples published in this journal: one provided by Levi et al. (1996) who investigated the effectiveness of art as a teaching strategy in educating children about death and the other by Spouse (2000) who used art work with other strategies to investigate nurse students’ professional knowledge in clinical settings. This paper by Coad provides information on how art-based techniques and activities can be applied for use in consultation work and research projects with children and young people and banishes the notion that artistic talent is needed for success in this area.The author states that ‘the increased emphasis on the active involvement, participation and consultation of children and young people as users of the health service requires, if participation is to be effective and sustainable, a move to participatory methods that are specifically devised to engage children’. Language difficulties and adult–children barriers are more likely to be overcome with pictorial communication than with words. Art, in its broadest form, offers the researcher unparalleled opportunities for investigation, perhaps rendering the often used analogue scale obsolete! It is to be hoped that this excellent paper inspires other researchers to consider art as a research medium where appropriate.

Clinical leadership characteristics confirmed

In view of the recent headlines that the newly formed NHS Commissioning Board must encourage nurse leadership (Independent Nurse, 2012), this paper is a welcome opportunity for policy makers, managers and clinical staff in the health services to take a good look at how many of their preconceptions fall short of reality. The work described is not rocket science, it is about finding out what makes a good nurse or paramedic, who really leads when it comes to standards and quality. ‘Quality’, when I use it here, is not merely value for money, it is about compassion, caring, something that so often seems to be overlooked in today’s health care judging by the number of complaints against the NHS (Patients’ Association, 2011). And at a time when, in the UK at least, standards seem to be dropping in tandem with the current funding crisis, it is a foolish manager who dismisses such research as ‘light’ or anecdotal. Certainly the response rates are low – could it be that staff is too disaffected to partake? Does that alter the validity of those who cared enough to see the research through? The importance of this paper is that, despite its simplicity, it distils decades of health care studies in relation to quality care. I bring to mind – though there were and possibly still are those policy makers who would prefer that I did not – the work of Carr-Hill et al. (1992), which looked at skill mix and the effectiveness of nursing care. Studies were largely based on the mistaken premise that a huge demographic blip would reduce the UK’s input of potential qualified nurses. Despite this not being the case, indeed we have UK-trained nurses unable to obtain posts in the NHS as cheaper staffing options have been pursued, and there is an economic drive for policy makers not to change their habits. The work of Carr-Hill et al. (1992), though in many ways exploratory, indicated clearly that care directed by qualified staff met with higher satisfaction and effectiveness, findings further supported by subsequent work such as that by Buchan (2002, 2004). Focusing less directly on skill-mix but still pursuing the issue of quality in health care, Maben and Griffiths (2008) consider leadership and ownership fundamental. The other side of the professional coin is highlighted by Saks (2009) who identifies techniques employed on both sides of the Atlantic which, while masquerading as being for the public good, were more inclined to benefit the professionals involved! A plea for increased numbers of qualified staff may