Workplace Supervision for Advanced Practice 2020 – An integrated multi-professional approach for practitioner development.

Summary

This guidance for workplace supervision of advanced clinical practice development will be useful for supervisors, employers, those driving workforce development and educators. There are seven fundamental considerations, set out in the diagram opposite, which underpin workplace supervision and ensure that both patient and professional safety are maintained during the practitioner’s advanced clinical practice development.

Multi-professional advanced clinical practitioners are a growing part of the modern healthcare workforce. Their valuable contribution to patient care and pathways is recognised in health and care policy (NHS, 2020). They are registered practitioners from a range of professional backgrounds who have advanced level capabilities across the four pillars of clinical, leadership and management, education and research, as set out in the The Multi-professional Framework for Advanced Clinical Practice in England, (NHS, 2017). Development in advanced clinical practice usually combines practice-based (workplace) learning and training with academic learning at level 7, (masters), delivered in a traditional higher education institution (HEI) such as a university.

The provision of workplace supervision which is responsive to a developing practitioner’s learning and development needs should be identified as part of advanced clinical practice workforce and business planning. It should be accompanied by investment in supervisor and practice educator development.

Aside from whether there is supervisor capacity in the existing workforce, it cannot be assumed that existing uni-professional workplace
supervision practices will map neatly to the learning needs of developing multi-professional advanced clinical practitioners/trainees. Nor can it be assumed that uni-professional colleagues have shared understanding of the professional scope or typical clinical practice profile of developing advanced clinical practitioner/trainees from different qualifying professions.

This is a rapidly developing field of multiprofessional practice across a growing range of settings and it is acknowledged that there will be
justifiable variation in supervision arrangements associated with geography, pathways, practice context and roles. Although supervision practices are well-established in health and social care, this resource has been developed because:

• There is variation in the extent to which advanced clinical practice and advanced clinical practitioners are established and recognised across the health and care system;
• Current supervision practices tend to have a profession-specific focus; both the practices and the accompanying terminology vary greatly within and across professions;
• Practitioners developing in advanced clinical practice come from an expanding range of registered professions; they are hybrid health and care professionals for whom there is no common, shared pre-registration foundation;
• Workplace supervision of advanced clinical practice knowledge and skills’ development is likely to include some supervision across traditional professional boundaries.

Contents

Ensuring that the fundamentals of advanced clinical practice supervision are adequately addressed can seem daunting and potentially raises concerns about resourcing. For this reason, the guidance in relation to each fundamental consideration is set out in sections with links to useful resources.

        

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The drivers that prompt the development of advanced clinical practice roles vary from service to service. Often a practitioner in an advanced clinical practice role is meeting practice demands and patient needs traditionally associated with another profession.

When designing workplace supervision for the developing advanced clinical practitioner/trainee, it is important to focus on the advanced clinical practice demands that the practitioner is expected to be competent and capable to assess, treat and manage rather than thinking about the practitioner as a substitute for a more familiar professional.

1.1 Resources to support the identification of advanced clinical practice demands

Existing job descriptions for uni-professional roles in the specified setting may provide

a helpful starting point but should be used with caution because of the

differing professional profiles of potential advanced clinical practice postholders.

It is useful to think about the practice demands in relation to the multi-professional framework for advanced clinical practice, considering how the practice demands fit with the core advanced clinical practice clinical, educational, research, management and leadership pillars and with the curricula and capability frameworks that have been and are being developed (see section 2).

Appendix 2has example activities which a team might conduct to help them to set aside traditional assumptions based on uni- professional approaches and job descriptions, and to focus instead on the advanced clinical practice demands. This approach can ensure that the added value brought to the advanced clinical practice setting through the expertise of professions less traditionally associated with this practice setting is not overlooked. The activities described in Appendix 2 may also be useful in supporting supervision or in peer learning sessions.

        

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Competence is used to refer to a consistent performance in accordance with defined standards and capability refers to being ‘competent, and beyond this, to work effectively in situations which may be complex and require flexibility and creativity’ (Skills for Health, 2020 p9)

The competences and capabilities inform the curriculum for development in advanced clinical practice for a specified setting. Curricula will reflect the required knowledge, skills, experiences, personal qualities, behaviours and attributes in relation to the advanced clinical practice pillars of clinical, education, research and leadership/management.

An advanced clinical practice role may share competences and capabilities with more traditional, uni-professional team roles but the uni-professional competences and capabilities should not be adopted as a short-cut to the specification of advanced clinical practice competence and capability without due consideration. This is because, as highlighted in section 1, multi-professional advanced clinical practitioners are registered professionals working within different qualifying professional registrations to meet advanced clinical practice demands in a specified practice setting. Each professional registration varies in terms of the registered professional’s scope of practice, for example whether supplementary prescribing is within scope.

The national framework for multi-professional advanced clinical practice (NHS 2017) provides an overarching, high level structure for curriculum development mapped to the four pillars. Thinking about curricula in relation to discrete pillars helps to ensure the breadth of development is addressed but it is recognised that in practice the pillars overlap and are interwoven. In some practice contexts there are nationally agreed clinical curricula and capability frameworks; Royal College of Emergency Medicine (RCEM), Faculty of Intensive Care Medicine, (FICM), and so on. It is nonetheless important to reach agreement about the area-specific competences/ capabilities because there will be local and speciality variation both in day-to-day clinical practice and in relation to the academic underpinning for advanced clinical practice pillar development offered from local higher education institutions/universities.

Each locality and speciality will need to agree how the academic and practice components integrate to facilitate the learning required for specified components of the practitioner’s advanced clinical practice development so that learning, academic and practice supervision, assessment and verification can be differentiated, co-ordinated and quality assured.

Where the development of advanced clinical practice is via the integrated degree apprenticeship route, the integration of academic and practice development will also need to map to the Advanced Clinical Practitioner (Degree) apprenticeship standard (ST0564).

Higher education providers/universities have the opportunity for accreditation by Centre for Advancing Practice curricula. These curricula will be subject to periodic review and re-accreditation.

Recognising the potential for operational and/or population changes and for specialty advances, it is also important to have regular, scheduled review of local curricula, for example when a cohort of learners complete their development, so as to ensure the competences, capabilities and related curricula remain fit for the development of advanced clinical practice in the specified setting.

2.1 Resources for agreeing advanced clinical practice competence and capability

Some speciality and area-specific curricula, competence and capability frameworks have been developed and include:

• Royal College of Emergency Medicine (RCEM) Emergency Care Advanced Clinical Practice Curriculum
• Faculty of Intensive Care Medicine, (FICM) Advanced Critical Care Practitioner Programme
• The Ophthalmic Common Clinical Competency Framework – Curriculum (OCCCF)
• Musculoskeletal Core Competency Framework
• Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice / Primary Care in England

Work continues nationally to agree competence and capability frameworks for advanced practice in different clinical settings and will become available as they are agreed via this website.

        

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The multi-professional nature of the advanced clinical practice workforce differentiates it from other health and care provision by registered professionals. This has implications for recruitment into advanced clinical practice development/trainee posts and the accompanying education and practice- based workplace supervision because:

• Developing practitioners/trainees will have different professional starting points reflecting different professional registrations, prior practice and supervision experience; nurses, pharmacists, allied health professionals (AHPs)² and so on;

• There is no single underpinning, pre-registration professional training for practitioners developing to an advanced clinical practice level. This is in contrast to the way that practitioners such as nurses or doctors, though ultimately specialising, share common pre-registration foundations for their respective professions;

• The scope of practice for different registered professions varies; for example, not all professional registrations extend to independent or supplementary prescribing³;
• Advanced clinical practice workplace supervisors and those they supervise may hold different registrations and it cannot be assumed that their experiences, beliefs and expectations about supervision are the same.

The training and development of advanced clinical practice workplace supervisors should address familiarisation with professional registrations, professional scope of practice and the implications for advanced clinical practice. It follows that such training would also encourage supervisors to be familiar with the scope of the pre-registration curricula for any supervisee whose registration differs from that of the supervisor.

Familiarity with the developing practitioner’s/ trainee’s qualifying registration and scope of practice underpins:

• Expectations about the developing advanced clinical practitioner’s/trainee’s pre-existing clinical knowledge and skills;

• The learning and development which will support the practitioner to augment existing knowledge, skills, experiences, behaviours and characteristics to an advanced clinical practice level;

• The design, provision and delivery of workplace supervisory practices which ensure practitioner and public safety during the practitioner’s advanced clinical practice development and beyond into ongoing practice.

3.1 Resources to support understanding of multi- professional registrations and scope of practice

The main professional regulators/registration bodies for professions working in advanced clinical practice in the NHS in England are:

• Nursing and Midwifery Council, (NMC)
• Health and Care Professions Council, (HCPC)
• General Pharmaceutical Council, (GPhC)
• Academy for Healthcare Science (AHCS)

For further discussion of the development of supervisors for multi-professional advanced clinical practice see section 7and for an outline of the indicative content for advanced clinical practice supervisor training and development see Appendix 6.

        

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Developing an individual learning plan (sometimes called a personal development plan), begins with an appraisal of the professional’s learning needs. This provides a mechanism to document:

• each practitioner’s existing professional knowledge, skills, experiences, behaviours and characteristics;

• each practitioner’s development plan; agreeing which aspects of the existing knowledge, skills, experiences, behaviours and characteristics will need to be augmented in practice and off-the-job, to ensure competent, capable, safe and effective advanced clinical practice;

• a baseline against which to track and record development in the specified capabilities and competences for the target advanced clinical practice role;

• the acknowledged added value different professional registrations bring the practice setting for patient benefit.

How far a practitioner is from the advanced clinical practice level will vary from professional to professional, reflecting the combination of

professional registration, pre-registration curriculum and subsequent practice-acquired knowledge, skills and experiences. With a range of highly experienced registered professionals developing in advanced clinical practice, an appraisal of learning needs helps to identify where and in what ways the practitioner is at, or close to, the advanced clinical practice level and where the practitioner has more significant learning and development needs and/or priorities in relation to the four pillars of advanced clinical practice. The appraisal of individual learning needs informs the development of an individual learning plan which:

For a given workplace/practice setting, a consistent approach should be adopted for both learning needs analysis and the individual learning plan; using consistent documentation and templates. For advanced clinical practice degree apprentices, an initial learning needs.analysis (INLA) is obligatory to ascertain which academic modules of learning are required.

It is anticipated that a learning development plan will include a range of workplace learning and development activities which might include Direct Observation of Practical Skills (DOPS), Case based Discussion (CbD), Observed Clinical Event (OCE), Supervised Learning Event (SLE), Clinical Exercise (CEX) and so on. These learning and development approaches are well-established in some professional groups and less so in others, so it cannot be assumed that the developing advanced clinical practitioner/ trainee is already familiar with these formats.

Discussing and agreeing the learning development plan provides an opportunity to introduce the developing advanced clinical practitioner/trainee to the range of possible learning activities, which are relevant for the identified development and to agree who is best placed to provide supervision for these.

4.1 Resources to support individual learning planning

In some settings a learning needs analysis approach may already be established or there may be a similar process which could be adopted such as a Personal Development Plan (PDP). Existing processes can be adopted but should be reviewed to ensure there is good fit with the multi- professional development considerations such as cross-profession supervision and verification.

NHS England are developing a number of portfolio routes leading to recognition by the Centre for Advancing Practice. A portfolio portal will be available to support education programmes if required, and individuals Continuing Professional Development. A repository of learning plan and portfolio resources developed as part of the Core Capabilities Framework for Advanced Clinical Practice here.

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Healthcare professionals are familiar with multi- professional practice settings and the respective contributions each profession makes to patient care. However, multi-professional advanced clinical practice is not yet consistently established across the health and care workforce. There is variation both regionally and across specialties and/or practice settings. Advanced Clinical Practice roles are more developed and defined in some settings and for some professions. As a result, advanced clinical practitioner roles are not consistently recognised by fellow health professionals or by the public in the same way that traditional uni- professional roles are recognised and understood.

Socio-professional perceptions, expectations and experiences of professional identity and the transition to a new professional role or identity are not unique to advanced clinical practice development but are an important consideration given the hybrid⁴ professional status of advanced clinical practitioners. The impact for developing practitioners/trainees of the transition from a uni- professional to a dual socio-professional identity, combining qualifying professional registration with an advanced multi-professional role is recognised in the research literature, (Moran and Nairn, 2017).

Socio-professional factors may have greater impact in practice settings where there is an integrated multi-professional advanced clinical practice workforce (critical care, emergency care, surgical pathways) or where advanced clinical practice underpins an emergent healthcare role such as First Contact Practitioners in primary care settings (NHS 2019).

Workplace supervision for the practitioner who is developing in advanced clinical practice should recognise:

• from the outset, the developing advanced clinical practitioner/trainee is already an established clinician often practising autonomously and at a high level, in a role traditionally aligned with their qualifying professional registration;

• during development and beyond, advanced clinical practitioners do not have a separate professional registration or become eligible for a different professional registration. They remain a registrant in their qualifying profession, practising within the scope of the qualifying registration at an advanced level;

• in a multi-professional practice context, the practitioner’s knowledge, skills, experiences, behaviours and characteristics equip the advanced clinical practitioner to meet presenting clinical and wider practice demands which are not uniquely aligned with one single professional registration;

• as an emerging level of multi-professional practice, an advanced clinical practitioner who meets practice demands more usually associated with one or other registered profession may encounter some uncertainty about the role from fellow professionals and from the public.

Importantly, the advanced clinical practitioner is a registered professional meeting practice demands within the scope of their own professional registration and adding value to the clinical pathway; not as a substitute for another profession.

5.1 Resources to support factors and issues of professional transition

The key resource for the support of socio- professional factors and issues of professional transition is access to supervisors who are insightful about the different uni-professional starting points for the developing advanced clinical practitioners/trainees and alert to the impact of socio-professional considerations.

It is important that multi-professional and socio-professional considerations are explicitly discussed and explored in supervisor learning and development opportunities, as described in section 7 and Appendix 6.

        

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Some employers have established, designated ‘Trainee Advanced Clinical Practitioner’ roles with protected development time both in-practice (workplace) and off-the-job. However, this is not always the case. Either way, registered professionals developing in advanced clinical practice will be balancing day-to-day practice demands and the maintenance of patient safety, with their own learning, development and professional registration requirements for ongoing clinical and managerial supervision, while seeking to maintain both professional and personal well-being.

It is unrealistic to propose that a single supervisor, however skilful, will be equipped to support the breadth of development necessary across all four advanced clinical practice pillars of clinical, research, education, leadership and management, while also supporting the developing practitioner/trainee with the competing workplace demands. For this reason, in common with other areas of workplace health professions’ training, such as in medicine, dentistry or healthcare science (COPMeD, 2018; COPDEND, 2018; National School of Healthcare Science), an integrated approach to workplace supervision is necessary.

In the workplace, a developing practitioner/trainee in advanced clinical practice can expect to have an identified ‘Coordinating Education Supervisor’ and a number of ‘Associate Workplace Supervisors’ who support specified aspects of the practitioner’s specialty or area-specific knowledge and skills development in relation to the four pillars of advanced clinical practice.

An integrated approach with ‘Coordinating Education Supervisor’ and ‘Associate Workplace Supervisors’ is recommended because:

• currently there is no consistently adopted approach to workplace supervision in advanced clinical practice and a variety of advanced clinical practice supervision
• models and accompanying terminology are implemented across settings and regions;
• although there are examples where the medical trainee supervision model (COPMeD, 2018) and the terminology ‘Education Supervisor’ and ‘Clinical
• Supervisor’ have been adopted, there are also settings where there is limited overlap between the advanced clinical practice role and that of a medical trainee, and in these instances a medical trainee model fits less effectively;
• an ‘Associate Workplace Supervisor’ may be identified to support clinical development, as with the clinical supervisor in the medical training model but equally may
• be identified because of their expertise in another pillar of development: education, leadership/management or research.

It would be expected that to achieve the right match of supervisor knowledge and skills with a specified capability and/or competency for any given advanced clinical practice pillar, a workplace supervisor will not necessarily hold the same professional registration as the developing advanced clinical practitioner/trainee.

Identifying who already has the capabilities required in a specified practice setting can help identify who can support learning, development, supervision, assessment, verification and ongoing supervision, and whether those individuals will require additional developmental opportunities to ensure they are appraised of the aspects of advanced clinical practice which differentiate it from more traditional uni-professional practice, (see also section 7).

6.1 The Co-ordinating Education Supervisor:

The Co-ordinating Education Supervisor provides a consistent supervisory relationship throughout the practitioner’s advanced clinical practice development; guiding the practitioner’s development from uni-professional to hybrid professional at an advanced clinical practice level.

The Co-ordinating Education Supervisor will:

• Have an in-depth understanding of the advanced clinical practitioner’s role in the specialty, pathway or setting, including factors which may differentiate roles in advanced clinical practice from traditional uni-professional roles in the same setting;

• Have a high level of awareness of the range of potential professionals and respective scope of registration for each;

• Have an understanding of the practice-based and off-the-job components of advanced clinical practice development;

• Support the developing practitioner/trainee with socio-professional aspects of professional development;

• Support the developing practitioner/trainee to balance the competing workplace and development demands as an employed registered professional; signposting to more specialist professional or personal support when indicated;
• Have completed professional development which includes a focus on multi-professional supervision and practice-based education (see section 7);
• Guide and signpost the developing practitioner/ trainee to identify Associate Workplace Supervisors who can support specialty, pathway or setting-specific knowledge and skills;
• Ensure access to sufficient, structured, practice- based learning opportunities to ensure the practitioner can develop the agreed advanced clinical practice competences and capabilities;
• Ensure that competency and capability verification is conducted by a suitably authorised or approved registered professional;
• Act as a link with the designated higher education provider/university where required for both apprentice and non-apprentice development routes;
• Maintain an overview of the practitioner’s progress against an agreed individual learning plan and local/area-specific curriculum;
• Maintain an overview of and address issues of professional and public safety.

Development in advanced clinical practice combines level 7 academic (Masters’ level) learning with workplace/practice-based learning and skills’ development. Supervision for the developing advanced clinical practitioner/trainee needs to consider the relationship between workplace coordinating education supervision and other learning, development, clinical and operational governance activities. These include:

The relationship between advanced clinical practice trainee supervision, assessment and verification;

• The requirements for trainees who are developing as Advanced Clinical Practitioner Integrated Degree Apprentices (Degree Apprenticeship Standard: ST0564);

• Any pathway specific standards, competences or capabilities required for the advanced clinical practitioner’s role;
• The place and role of identified associate workplace supervision for advanced clinical practice specific skills development;

• The place for pastoral support;

• Supporting a transition from a traditional uni-professional to an advanced clinical practice professional identity.

6.2 Associate Workplace Supervisors:

Associate Workplace Supervisors are practice-based practitioners who are experienced in practice-based education and the supervision of experienced registered professionals. The developing advanced clinical practitioner can expect to work with a variety of associate workplace supervisors, each matched to support the development of specific, identified aspects of advanced clinical practice capability and/or competence. An associate workplace supervisor should be appraised of the multi- professional considerations associated with advanced clinical practice development and supervision.

Associate Workplace Supervisors will:

• work collaboratively with the coordinating education supervisor and the developing practitioner/trainee to support a specified aspect of advanced clinical practice development in a specialty, pathway or setting; guiding the practitioner’s development in the specified aspect of advanced clinical practice from uni-professional to a multi-professional advanced clinical practice level;
• have an in depth understanding of the specified aspect (clinical, education, leadership/management or research) of advanced clinical practice in relation to the practitioner’s specified advanced clinical practice role;

• have an awareness of the range of potential professionals and scope of registration for those developing in the advanced clinical practice setting;

• have completed professional development with a focus on supervision and practice-based education (see section 7)

6.3 Employer Responsibility

Advanced clinical practice development takes place in a live and dynamic clinical context in which there are multiple stakeholders in terms of both clinical, operational and educational governance. Each stakeholder’s immediate governance focus may differ. However, the overarching aim is to support practitioner development while simultaneously ensuring safe and effective care.

Recommendations following Kirkup (2015) have prompted a policy shift regarding supervision practices which separates regulatory aspects of supervision from professional development aspects, transferring the responsibility for workplace supervision from statute to employer.

An employer seeking to introduce advanced clinical practitioners into the workforce will need to factor the provision of workplace supervision for advanced clinical practice development into the local workforce strategy, recognising that this may entail investment in coordinating education supervisor and associate workplace supervisor capacity, capability and competence (see section 7).

Where advanced clinical practice workforce development is via the Advanced Clinical Practitioner Integrated Degree Apprenticeship, there are specified contractual requirements which employers must fulfill, (Institute forApprentices and Technical Education, 2018)

Health and care professionals engage in career- long learning and development. In advanced clinical practice development, employers will need to ensure that the balance between employee and learner demands are maintained. Job plans offer one way in which this may be agreed, documented and monitored.

6.4 Resources to support the development of an integrated approach to supervision for the developing advanced clinical practitioner

Appendix 5sets out possible barriers to workplace supervision and offers possible solutions.

As highlighted in sections 3 and 5, adopting approaches developed for a uni-professional context cannot be assumed to be best-fit for multi- professional advanced clinical practice. A framework or approach designed for a specified profession should not be adopted for use in multi-professional advanced clinical practice without due critical considerations of the strengths and limitations of the approach in the multi-professional context. Models and approaches designed specifically for the multi- professional context are beginning to be developed.

In the meantime, while advanced clinical practitioners are not substitute doctors, there are contexts where there is overlap between medical trainee roles and those of advanced clinical practitioners. Where this is the case, the approach to advanced clinical practice development has drawn on the medical model set out in ‘The Gold Guide’, the reference guide for postgraduate medical specialty training (COPMeD, 2018).

        

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Across the health and care system there are already resources, courses and programmes which aim to develop registered professionals as workplace, practice-based educators, supervisors and assessors. For medical professions there are structured learning opportunities for those supervising postgraduate medical trainees. Most of the other registered professionals are not regarded as trainees on graduation and the development of supervisors for such postgraduate, registered health professionals is more varied. For many health professionals, career development in clinical knowledge and skills is prioritised over development in practice- education or supervision knowledge and skills.

Supervision training has developed in and for single professional registrations; doctors, midwives, nurses, pharmacists, physiotherapists and so on. The content or curricula have some common features (see section 7.4).

To prepare workplace supervisors fully to recognise and support the differentiating factors of advanced clinical practice development such as the multi-professional nature of the role, differing professional registrations and issues of professional identity and socio-professional adjustment, existing supervisor training may need to be adapted and augmented.

Before considering how existing supervision training and development may need to be adapted for the advanced clinical practice context, a brief overview of common health and social care supervision themes, influences and practices is provided.

7.1 Common features of supervision in health and social care

Supervision practices are well-established in health and social care, but individual practices and accompanying terminology vary greatly within and across professions resulting in ambiguity about process and purpose. There are many models of supervision, although Proctor’s (2001) remains the most widely cited, (see Appendix 3). Developed in the context of nursing practice, it proposes multiple and overlapping formative, normative and restorative dimensions of supervision. Models of supervision are sometimes accompanied by models of professional development and skills’ acquisition. Those of Benner (1984) and Peyton (1998) are again widely cited and are also illustrated in Appendix 3. Some regard such models as too prescriptive and linear, implying an end point or a ‘best place’ for the professional to be positioned, (Dall’Alba and Barnacle, 2015).

The debate about supervision illustrates that important first steps in all supervision are to establish a common understanding between supervisors and supervisees about the purpose and to use terminology and definitions consistently. Establishing this common understanding is all the more important in a multi- professional practice context where supervisor and supervisee may hold differing views, understanding and experiences of supervision.

Models and frameworks can guide supervisors to attend to the multiple dimensions of and influences on the supervised practitioner’s practice but will not guarantee the effectiveness or quality of the supervision experience.

Additional factors which influence the effectiveness of supervision have been identified, (Rothwell et al 2019; Martin, Copley and Tyack, 2014) and include:

• Using effective communication and feedback
• Facilitating reflective practice
• Building a positive supervisory relationship with mutual trust and respect between supervisor and supervisee
• Separating clinical supervision from line management
• Choice of or access to multiple supervisors who are trained and have expertise matched to the supervisee’s presenting needs
• Shared understanding of the purpose of the supervisory sessions (e.g. an agreed contract)
• Focus on providing staff support, the sharing/ enhancing of knowledge and skills to support professional development and to improve service delivery
• Regularly scheduled supervision according to individual needs and ad-hoc in cases of difficulty
• Use of supervisory models based on the needs of the individual: one to one, group, peer supervision, internal or external to workplace, distance (including the use of technology) or use of more than one mode.
• Training and feedback for supervisors
• Flexibility to ensure all staff have access, regardless of working patterns
• Employer support for protected time, supervisor training and private space to facilitate the supervisory session

While it is important to protect regular, scheduled time for supervision, it is the quality and not the quantity of supervision which determines how effective supervisees perceive supervision is in supporting them as practitioners. The frequency and duration of good quality supervision will be determined by the demands of the setting and the developing practitioner’s/trainee’s capability and competence. There should be sufficient, regular supervision to ensure both professional and public safety are maintained.

Ultimately, supervision is perceived to be optimal when both supervisor and supervisee care about and care to resolve practice uncertainties or developmental needs, and when supervisor and supervisee adopt a cluster of facilitative behaviours and characteristics. Practitioners who display these characteristics can be described as ‘permeable practitioners’; they expect and anticipate uncertainty in day-to-day practice and seek to resolve uncertainties in a variety of reflective and learning activities, one of which may be supervision (Harding, 2019):

Importantly, permeable practitioners recognise the links between uncertainty, learning and the management of risk in clinical practice.

They also seek to harness the learning which is supported through supervision to celebrate supervisee success and to build on what works well in practice; further promoting both professional and public safety through the proliferation of effective practice. A practitioner permeability self-assessment resource is provided in Appendix 4.

Current approaches to supervision also encourage reflective practice. Schön’s (1983) distinction between reflecting after an event, (‘on action’) and circumstances in which an experienced practitioner adjusts practice while reflecting ‘in action’, remains influential. There are those who caution that experienced professionals should not become over-reliant on ‘reflection in action’ and that this should be accompanied by regular, scheduled opportunities such as workplace supervision to review the taken-for-granted, thus moderating tendencies to turn to off- the-peg solutions (Eraut, 1994). There are many readily available frameworks and models to support such scheduled reflection on action (Gibbs, 1988; Moon, 1999)

7.2 The relationship between supervision, patient safety and the prevention of harm

There is an established UK policy position which signals a governance role for supervision. This policy position, in which supervision is regarded as a means of preventing failures in care, is apparent in historic responses to high-profile untoward events, ranging from the actions of children’s nurse Beverley Allitt (United Kingdom, 1991) to events in Mid-Staffordshire (CQC 2013).

Policy may separate regulatory and professional development aspects of supervision but for the practitioner these aspects are often and necessarily more interwoven. Research and opinion indicate that overlooking professional development and the space to deliberately reflect on practice misses opportunities to build on what is working well and to identify where practice might require attention; to interrogate and challenge taken-for-granted practices (Manley et al 2018, Dall’Alba and Barnacle 2015, Eraut, 1994).

Even so, the role of supervision in the governance of healthcare practitioners has remained one of voluntary best practice, with the exception of midwives in the UK for whom supervision was established as a statutory obligation from 1902 (United Kingdom, 1902). However, statutory status could not and did not eliminate professional failures and consequent harm, so following the investigation of NHS maternity services in Morecombe Bay during the period from January 2004 to June 2013 (Kirkup, 2015), the UK Government (2017) recommended the removal of statutory requirement for supervision for midwives, bringing midwifery, into line with other registered health and care professions in the UK. This change signals a policy shift regarding supervision practices which separates regulatory aspects of supervision from professional development aspects and transfers the responsibility for supervision practice from statute to employer.

7.3 Barriers and Facilitators of effective supervision

Although supervision practices are widely supported and endorsed throughout health and care policy and by the professional regulators, there are also acknowledged barriers, both organisational and personal (Bush, 2005).

Organisational barriers include the resourcing of workplace supervision, productivity challenges associated with supervision as a non-patient-facing activity, and the availability and prioritisation of training for supervisors. Personal barriers include perceptions that supervision is not relevant and dissatisfaction with the supervision available. For some health professionals, the reporting of high profile professional conduct cases have prompted mistrust of the purpose of structured supervision and associated reflective practice, (Vaughan, 2018; Hodson, 2018); consistent with concerns that supervision and reflection may represent a form of surveillance, (Gilbert, 2001).

Appendix 5 sets out commonly encountered supervision barriers and proposes some ways in which barriers may be overcome and/or supervision more satisfactorily facilitated.

7.4 Developing supervisors: features of existing supervisor training

Commonly, the content of healthcare supervisor training and curricula includes:

• Communication skills including; facilitation, coaching, negotiation, resolving conflict and strategies for difficult conversations, creating the conditions for effective supervision; providing feedback.
• Critical reflection; theories, models and frameworks.
• Models of skills’ acquisition, including in some instances, presenting a preferred model and in others developing critical awareness of different models of skills acquisition.
• Differentiating the practitioner in difficulty from the practitioner with difficulties and/or the difficult practitioner.
• When to sign-post to another form of personal, professional or psychological support; including supporting and managing the practitioner in difficulty.
• Models of supervision, including in some instances, presenting a preferred model and in others developing critical awareness of different models of supervision.
• Learning models, styles and preferences and accompanying critique.
• Clinical and professional governance including patient safety, professional safety, the management of risk, confidentiality, statutory duties, duty of candour; uncertainty in professional practice; professionalism.
• Professional well-being.

7.4.1 Augmenting supervisor development to support advanced clinical practice development

Training for workplace supervisors supporting advanced clinical practice development should seek to contextualise the common features as described in section 7.4. Existing workplace supervisor training and development opportunities may therefore require augmenting and adapting. In section 7.1 practitioners who display a cluster of behaviours and characteristics which facilitate supervision in all aspects of health and social care practice were described as ‘permeable’. In the advanced clinical practice context, this cluster of behaviours and characteristics can be valuable in preparing the supervisor for clinical or professional governance and/ or socio-professional ambiguities which may arise in relation to the supervision of a colleague who holds a different professional registration and scope of practice.

In addition to the commonly encountered features of supervisor training, as a minimum, training for supervisors of developing advanced clinical practitioners/trainees should include:

• exploring the behaviours and characteristics which support the identification and resolution of practice uncertainties through supervision: developing supervisors who are self-aware, aware of and for others, are awareness-sharing, feedback-seeking, open to alternatives, critically aware/appraising and are willing to change/have a learning disposition;
• developing an awareness of the variations in professional registrations and scopes of practice;
• recognising the developing advanced clinical practitioner/trainee as an experienced registered professional; identifying what that professional already knows and what value can be realised with the addition of this professional knowledge and know-how to the team;
• considering advanced clinical practice development as an augmentation of existing competences and capabilities;
• recognising the links between practice uncertainties, learning, the management of risk and the maintenance of professional and public safety;
• developing an awareness of the socio- professional adjustments which accompany becoming an advanced clinical practitioner; issues of professional and hybrid identity for the practitioner, colleagues and for the public;
• and managing competing practice, education, professional and personal dimensions of being a developing advanced clinical practitioner/trainee.

7.4.2 Matching supervisor training with the workplace supervisor’s role: Considerations for Coordinating Education Supervisors and for Associate Workplace Supervisors

The indicative training content provided in Appendix 6is comprehensive and many aspects will already be identifiable in existing supervisor training. The appendix can be used to identify where existing training may need to be adapted or augmented for advanced clinical practice.

Adopting the integrated approach to supervision described in section 6, Coordinating education supervisors will require a more in-depth understanding of the factors which differentiate workplace supervision for multi-professional advanced clinical practitioners from supervision in more usual uni-professional contexts. In most instances, even highly regarded and experienced supervisors will have developed supervisory knowledge and skill in a largely uni- professional context and therefore will benefit from some developmental opportunities to explore the differentiating factors and nuances of professional development in advanced clinical practice. A coordinating education supervisor will benefit from training that has addressed all the indicative content. Where the coordinating education supervisor has already attended other forms of health and care professions’ supervision development, the indicative content can be used to self-assess whether there are further areas of development which will enhance their advanced clinical practice supervision expertise.

A proportionate approach to training and development for the two different workplace supervisor roles is encouraged; associate workplace supervisors will require an awareness of the differentiating factors for the developing advanced clinical practitioner/trainee but arguably not in the same depth as a coordinating education supervisor.

In any given setting, those with overall responsibility for workplace supervision of advanced clinical practice development will need to agree the extent of augmented training which is relevant for associate workplace supervisors, commensurate with the scope of the associate’s supervisory responsibilities and the professional registration of those whose development is being supervised.

7.4.3 Ongoing support for co-ordinating education supervisors and for associate workplace supervisors

In common with all aspects of professional practice, all supervisors should engage in a periodic refresh of training. This is particularly important in a new and evolving area of health professions’ supervision. Employers should maintain a log of supervisor education/training and subsequent updates. As a new and evolving area there will be a good deal to learn so employers or regions may wish to consider establishing:

• A formal community of advanced clinical practice workplace educators and supervisors
• Learning events with a focus on advanced clinical practice supervision
• Learning sets for advanced clinical practice supervisors

7.5 Resources Supervisor development and ongoing support

Appendix 6 provides indicative content for advanced clinical practice supervisor training.

The Royal College of Surgeons of England (RCS) provide educator training mapped to the General Medical Council standards for the recognition and approval of trainers. The training is open to Advanced Clinical Practitioners who have associate membership of the RCS.

Materials developed by the Centre for Pharmacy Postgraduate Education: General advice for supervisors Supervisor Training Resources:

Clinical Supervisor Training Video Learning and Assessments

NHS Education Scotland have a suite of clinical supervision training resources (not specifically focused on advanced clinical practice)

        

Continued support for the advanced clinical practitioner

This guide has set out what should be in place for the workplace supervision of registered health professionals developing in advanced clinical practice. Once the practitioner’s training is complete, as with any registered health and care professional, there is a requirement for ongoing professional supervision as part of continuing professional development. The considerations about multiple professional registrations and the hybrid nature of the advanced clinical practice role remain relevant for post-training advanced clinical practice supervision; a consideration that employers will need to be satisfied is sustained beyond the training phase.

Over time, it would be expected that there will be increasing numbers of trained practitioners with competence and capability across the four pillars of advanced clinical practice: Clinical, Research, Education, Leadership and Management. Each cohort of trained practitioners will add to the numbers of multi-professional advanced clinical practice educators and supervisors who, in turn, are able to support the next generation of advanced clinical practitioners. In the meantime, there will be a need to adapt and augment existing uni-professional approaches to meet the workplace supervision requirements for advanced clinical practitioners.

        

Appendices

Appendix 1:

Supervision Glossary of Terms and Abbreviations – Updated 2020

In developing guidance, we have encountered variations in the terminology used in both supervision and advanced clinical practice.

There are a variety of terms, interpretations and understandings of the language used. We have used terminology and abbreviations as follows:

Advanced Clinical Practice Advanced Clinical Practice:

A defined level of practice within clinical professions such as nursing, pharmacy, paramedics and occupational therapy. This level of practice is designed to transform and modernise pathways of care. Enabling the safe and effective sharing of skills across traditional professional boundaries. NHS England Definition. It is acknowledged that in some healthcare settings, the terms ‘advanced practice’ and ‘advanced practitioner’ are preferred.

Advanced Clinical Practitioners:

Healthcare professionals, educated to Master’s level or equivalent with the skills and knowledge to allow them to expand their scope of practice to better meet the needs of the people they care for. ACPs are deployed across all healthcare settings and work at a level of advanced clinical practice that pulls together the four Advanced Clinical Practice pillars of clinical practice, leadership and management, education and research. NHS England Definition

Developing Advanced Clinical Practitioner/Trainee:

An experienced practitioner from a variety of registered professions such as nursing, pharmacy, and allied health professionals such as paramedic, physiotherapy and occupational therapy who is engaged in a period of Master’s level academic and workplace/practice development to expand and augment their scope of practice to an advanced clinical practice level. The term Trainee Advanced Clinical Practitioner is established in some settings and in others the term Developing Advanced Clinical Practitioner is preferred to distinguish the practitioner from post-graduate medical trainees. To acknowledge this variation, we have adopted the hybrid ‘Developing Advanced Clinical Practitioner/Trainee’ in this publication.

To avoid conflating the notions of advanced clinical practice (a level of practice) and that of advanced clinical practitioner (an individual working at the level of advanced clinical practice) the abbreviation ACP has not been used in this guidance.

Competence and Capability Competence:

To consistently perform to defined standards required in the workplace, usually focused on the outputs of work and observable performance. Competence tends to describe practice in stable environments with familiar problems. Skills for Health Definition

Capability:

The ability to be competent, and beyond this, to work effectively in situations which may be complex and require flexibility and creativity. Skills for Health Definition

Supervision and Supervisors in Healthcare

A review of published literature and guidance reveals there are very many definitions of the terms Supervision and Supervisor.

Clinical Supervision:

Clinical supervision provides an opportunity for healthcare practitioners to reflect on and review their clinical practice, discuss individual cases in depth and identify changes or modifications to practice which are required to maintain professional and public safety. It provides an opportunity to identify training and continuing development needs. CQC (2013)

Professional Supervision:

Professional supervision is often interchangeable with clinical supervision or as an overarching term to include both clinical and managerial aspects of supervision. The CQC (2013) suggest the term is sometimes used where supervision is carried out by another member of the same profession or group, providing the practitioner with opportunities to review professional standards, keep up to date with profession-specific developments, training and continuing development, ensure compliance with professional codes of conduct and boundaries.

Managerial Supervision:

Managerial Supervision and line management maybe used interchangeably. The CQC (2013) suggest managerial supervision is provided by someone with authority and accountability for the supervisee. It provides the opportunity for performance review, setting priorities/ objectives in line with the organisation’s objectives and service needs and identifying training and continuing development needs.

Supervision and Supervisors for Advanced Clinical Practice Development/Training Co-ordinating Education Supervisor:

A registered healthcare professional who provides a consistent supervisory relationship throughout the practitioner’s advanced clinical practice development; guiding the practitioner’s development from uni-professional to hybrid advanced clinical practice level. The supervisor will not necessarily hold the same professional registration as the developing advanced clinical practitioner/trainee but will be experienced in supervision and in the relevant field of advanced clinical practice. The role is similar to that of the Education Supervisor in medical training but in advanced clinical practice development, takes account of the potential for supervisor and supervisee to hold different professional registrations.

Associate Workplace Supervisor:

Associate Workplace Supervisors are practice-based practitioners who are experienced in practice-based education and the supervision of experienced registered professionals. The developing advanced clinical practitioner/trainee can expect to work with a variety of Associate Workplace Supervisors, each matched to support the development of the specific, identified aspects of advanced clinical practice capability and/or competence against the pillars of advanced clinical practice. As such, an associate workplace supervisor may be identified because they are matched to supervise clinical, education, leadership/management or research aspects of the practitioner’s advanced clinical practice development.

Other terms used in Centre for Advancing Practice supervision guidance:

Pillars of advanced clinical practice:

NHS England sets out capabilities for advanced clinical practice in relation to four core pillars: clinical practice, leadership and management, education and research. These may be manifested/demonstrated in different ways depending on the profession, role, population group, setting and sector in which an individual is practising.

Practice Demands:

In this guidance the phrase ‘practice demands’ is used to refer collectively to all the advanced clinical practice expectations in relation to the four pillars: clinical, education, leadership and management, research.

Practitioner permeability:

Practitioner permeability is used in this guidance to refer to a collection of behaviours and characteristics which support both supervisor and supervisee to expect, anticipate and seek to resolve uncertainties and concerns which are encountered in the course of day-to-day practice. These behaviours and characteristics are: self-awareness, awareness of and for others, awareness-sharing, feedback-seeking, openness to alternatives, critical awareness and willingness to change/learning disposition. Permeability supports practitioners to recognise the relationships between uncertainty, learning and the maintenance of professional and public safety.

Verification:

Akin to ‘sign-off’ in some uni-professional contexts this refers to the process of verifying a practitioner’s level of practice and capability

Abbreviations used in Centre for Advancing Practice supervision guidance

AHP Allied Health Profession(al)

COPMeD Conference of the Postgraduate Medical Deans of the United Kingdom

CQC Care Quality Commission

FICM Faculty of Intensive Care Medicine

GPhC General Pharmaceutical Council

HCPC Health and Care Professions Council

HEI Higher Education Institution

NHSE NHS England

NHSI NHS Improvement

NMC Nursing and Midwifery Council

RCEM Royal College of Emergency Medicine

        

Appendix 2: Working out the advanced clinical practice demands in a specified practice setting.

Exercise 1

1. Make a list of about 15 patients you have seen as a team. You might just pick the last 15 but you should be satisfied there is a mix of complexity of clinical needs; ones who are more ‘usual’ and ones who are more complex.
2. Put the names of the patients on individual cards – turn them over so that you cannot see the names.
3. Pick three of the cards at random. Turn them over and in different combinations, discuss how two of them are similar but different from the third. The similarities and differences might be clinical, social, emotional, cultural, operational (discharge planning, ordering equipment) and so on. Think about all the ways in which the team support the individuals with their health condition(s) and the impact for those individuals.
4. Capture all your ideas in a list (a list of the practice demands in your setting). You can then use the list to think about the competences and capabilities that are required to meet those practice demands, which of those are required at an advanced level and who is best placed to supervise the advanced clinical practitioner for each aspect of practice.

Exercise 2

In exercise 1 all those taking part in the activity ideally need to be familiar with all the patients. In some settings this might be more difficult, for example in primary care, community settings or where there is high patient turnover as in emergency care. This second exercise may work better in those settings. It is essentially the same as exercise 1 but instead of using patients, gather a large collection of postcards or use a free picture resource e.g. Unsplash.

1. Spread out the cards and get colleagues to select a few cards that ‘represent’/’remind them of’ patients they have seen. You might encourage colleagues to pick a card that represents a straightforward clinical encounter and one that represents a more challenging encounter.
2. Get colleagues to write down all the practice demands associated with that encounter; clinical, social, emotional, cultural, operational (discharge planning, ordering equipment) and so on. Think about all the ways in which the team/practitioner supports the individuals with their health condition(s) and the impact for those individuals.
3. Capture all your ideas in a list (a list of the practice demands in your setting). You can then use the list to think about the competences and capabilities that are required to meet those practice demands, which of those are required at an advanced level and who is best placed to supervise the advanced clinical practitioner for each aspect of practice.

Appendix 3: Popular supervision, skills acquisition and professional learning models

Models and frameworks can be helpful in providing frameworks for both supervision and for supervisor training and development. Proctor’s model of supervision and the skills’ acquisitions models of either Benner or Peyton, remain widely cited. As with all models and frameworks, it is important to apply some critical awareness, considering the strengths and limitations of each model in the context in which it is used.

Models

Appendix 4: Helpful supervision behaviours and characteristics self-assessment/ reflective questions (practitioner permeability)

Questions

Awareness of Self

How good am I at acknowledging gaps in my knowledge? Do I expect to have all the answers? How do I feel about not knowing? How comfortable am I with uncertainty? 

Awareness of Others

In what ways do I compare myself with colleagues/fellow practitioners? How does this influence me/my practice?

Awareness for Others

In what ways do I look out for colleagues? How do I decide when to step in?

Awareness Sharing

How willing am I to share my uncertainties with others? Who do I choose to share uncertainties with? What supports me to share uncertainties? Do I encourage others to share uncertainties with me? Do I see uncertainties as an opportunity for learning? Do I tend to see uncertainty as an indicator of risk?

Feedback Seeking Orientation

Do I seek feedback? Do I regard feedback as part of learning? Do I avoid or disregard feedback? Do I seek feedback from a range of people? Do I tend to seek feedback from the same people? If so, why?

Openness to Alternatives

Do I tend to think the way I have always done things is best or right? If so, what makes me think this? How much flexibility am I willing to tolerate? Am I willing to try new approaches? Am I willing to listen to another’s perspective? 

Critical Awareness / Agency

What influences whether I am willing to make changes in my practice or practice behaviours? How do I decide whether to change aspects of my practice? Do I have preferences for certain sorts of evidence? Do I tend to think some evidence is more important than others? 

Willing to Change / Learning Disposition

Am I willing to try a new approach or behaviour?

Am I willing to persevere with alternatives, or do I tend to stick with things I am familiar with? Am I likely to think that changing my practice makes it look like I was wrong before?

Harding (2019)

Appendix 5: Overcoming barriers to supervision

Some of the barriers identified here apply to supervision across the health and care system while others are barriers which are more specific to the advanced clinical practice context. In most cases, supervision arrangements for advanced clinical practice will be a subset of a healthcare provider/employer’s wider workforce supervision and governance and for this reason advanced clinical practice supervision barriers have been considered alongside wider system barriers. This is not a definitive set of barriers or possible solutions and is intended to provide a starting point from which to begin to address barriers which are being encountered in a specified setting where advanced clinical practice development is being supported. Possible solutions are not limited to specific barriers.

Barriers and possible solutions

Barriers	Possible solution
Resourcing pressures: • Patient-facing activity prioritised • Supervision regard as a challenge to patient-facing productivity • Limited resource allocation for training and development of supervisors	Ensure leadership awareness of: • employer responsibilities for supervision as part of workforce governance • links between supervision and both professional and public safety • relationships between professional/public safety and headline national metrics such as recruitment and retention and the links between staff vacancy rates, sickness absence and clinical productivity Supervisor training and development: • ensuring the provision of high-quality supervision is factored into workforce development strategy and business planning • where workforce initiatives seek to develop advanced clinical practice using the integrated degree apprenticeship route, ensure the workforce planning has taken account of employer responsibilities set out in the degree apprenticeship standard • including the provision of training and development in supervision as part of workforce development strategy • having monitoring processes to ensure supervision training and development is undertaken and updated • agreeing a ratio of trained supervisors to clinical staff which will ensure professional and public safety while optimising clinical productivity Additional resourcing: • ring-fencing of additional resources which may be offered in-year and developing a plan around the use of these funds, e.g. where Health Education England regions may provide funding to support advanced clinical practice development/trainee supervision
Capacity Pressures: • Limited availability of skilled and trained supervisors • Limited experience in multi- professional supervision and/or supervision for clinical practice	In addition to ‘Supervisor training and development’ and ‘Additional resourcing’ (as above) Supervisor training/ development and support with a focus on advanced clinical practice: • Developing or accessing supervisor development opportunities which specifically include content with a focus on multi-professional supervision and on advanced clinical practice (levels and roles) as detailed in appendix 6 • Reviewing existing supervisor development and training to adapt or augment to include multi- professional supervision and on advanced clinical practice (levels and roles) as detailed in appendix 6 • Establish networks, learning sets, peer support for supervisors providing supervision in the multi-professional advanced clinical practice context
Understanding of advanced clinical practice level and roles: • Advanced clinical practice not yet an established part of the workforce • Varied enthusiasm across team, professionals, practice settings for advanced clinical practice • Dominance of specified, uni-professional or traditional models of practice • Assumptions that established/ traditional uni-professional supervision will be fit-for-purpose	In addition to the above: • Establish/ nominate an ‘Advanced clinical practice lead’ within the organisation; agree the scope of this lead role in terms of strategy including workforce development and governance • Provide wider awareness-raising opportunities for the organisation and within teams regarding the potential value of advanced clinical practice • Ensure a focus on practice demands and patient needs rather than uni-professional starting points in training, development and awareness raising activities • Share advanced clinical practice exemplars within and beyond the immediate practice setting/provider, including examples of impact examples of impact on headline metrics such as length of stay, patient satisfaction, reduced waiting times • Encourage small scale quality improvement projects and/or audits to evaluate impact or potential impact of advanced clinical practice on headline metrics; recruitment and retention, length of stay, waiting times, pressure care and so on • Direct key clinical and operational leaders to access national and regional Health Education England advanced clinical practice resources via the Advanced clinical practice toolkit • Encourage key clinical and operational leaders to engage in and attend national and local events which focus on/showcase advanced clinical initiatives • Develop local advanced clinical practice ‘special interest group’ / forums/ journal clubs (actual or virtual)
Governance concerns: • Concerns about blurring of professional boundaries and responsibilities in practice • Associated concerns about accountability in multi-professional supervision • Uncertainty about different ‘types’ of supervision (educational, clinical, managerial and so on) • Confusing line management with clinical supervision or in roles combing clinical and team leadership, a dominance of operational and line management supervision • Tendency to regard supervision as a way to manage risk arising from uncertainty	In addition to the above: • Provide comprehensive training/development opportunities and updates for those delivering supervision across professions in the context of advanced clinical practice. • Ensure training and development includes attention to scope of practice for different professional registrations • Have local policy for the development of advanced clinical practice which clearly sets out lines of clinical and managerial responsibilities and accountability. • Ensure local policy provides guidance for resolving clinical or wider professional/ practice concerns where the boundary may blur between line management, clinical practice, academic progress and so on
Locality challenges: • Small provider organisation • Remote and lone working in community settings • Finding physical space for supervision	Collaborative approaches: • Using mechanisms such as training hubs and STP/ICS networks to pool supervision resources and ensure spread of supervision expertise/experience • Consider innovative and digital solutions including video-conferencing supervision, e.g. South Yorkshire and Bassetlaw ECHO • Include the identification of space for supervision at a planning stage • Identifying and booking space where feasible in advance of a scheduled supervision session • Supervisor and supervisee agreeing within the supervision agreement what constitutes a suitable physical space for supervision to take place.
Supervisee suspicion about purpose of supervision: • Concerns about surveillance • Perceptions based on previous unsatisfactory supervision experiences	Supervisee suspicion about purpose of supervision: • Concerns about surveillance • Perceptions based on previous unsatisfactory supervision experiences
Supervisee regards supervision as irrelevant: • Potentially an experienced practitioner with established approaches to practice • May have limited perspective about scope of supervision based on previous experiences of supervision • May consider available supervisors are unsuitable • May consider reflection in action is sufficient for safe practice	Professional registration responsibilities: • Awareness refreshers for health profession registrants about their professional responsibilities to engage in supervision • Awareness refresher regarding the relationship between supervision and both professional and public safety Additional professional development possibilities • Opportunities which include the development of ‘permeable’ behaviours and characteristics (see appendix 4) • Ensuring matching of supervisors to supervisees maintains a practice demands and specified capability/ competency focus rather than a professions’ focus
Issues of prioritisation • Practitioners (supervisee and/or supervisor) see clinical work as the priority	See earlier possible solutions which encourage the development of: • Awareness of the links between supervision and professional/public safety. • Learning and development opportunities which highlight the inter- professional duty of care between one professional and another
Uncertainty about supervision from another registered profession: • Supervisee concerns that a supervisor with a different professional registration will not have sufficient understanding or insight about the supervisee’s profession and scope of practice • Supervisor concerns about unfamiliarity/ limited understanding of a supervisee’s professional registration and scope of practice where this differs from the supervisor’s profession and registration • Assumptions about professions, registrations and scope of practice	See earlier possible solutions which include: • Training which includes awareness of variations in scope of practice for different registered professions • Supervisor development which has a practice demand, capability and competency focus rather than a professional focus
Interpersonal factors: • Conflicts of interest (declared or undeclared) • Personality clashes • Communication styles	Additional professional development possibilities which include: • Supervisor development which includes exploration of communication skills, approaches to feedback provision, negotiation and conflict resolution • Agreeing at the outset of supervision how conflicts will be resolved • Regular evaluation of supervision effectiveness and satisfaction

Appendix 6: Indicative Advanced Clinical Practice supervisor training content

Content

An overview of Advanced Clinical Practice

• The national framework, pillars, levels of practice, roles.

• Training routes and mechanisms; relationships with HEIs, apprentice routes and standards.

• Identifying the advanced clinical practice demands in a specified setting.

• Identifying the level of advanced clinical practice required to meet the advanced clinical practice demands in a specified setting: knowledge, skills, experiences, behaviours and characteristics, agreeing or agreed competences relevant to the setting including national frameworks where relevant (FICM, RCEM etc).

 Multi-professional considerations in advanced clinical practice

• Developing an awareness of the variations in professional registrations and scope of practice.

• Recognising the developing advanced clinical practitioner as an experienced, registered professional; identifying what that professional already knows and what value can be realised with the addition of this professional to the team.

• Considering advanced clinical practice development as an augmentation of existing capabilities and competences.

Defining supervision

• Outline of supervision for health professions acknowledging the debate and possible differing uses of the same terms.

• Differentiating distinct types of supervision where these apply for a given profession e.g. education supervision and clinical supervision in medical training.

• Exploring how supervision applies in the development of advanced clinical practice; coordinating education supervisors and associate workplace supervisors.

Models of supervision

• Encouraging critical awareness of different models of supervision; their strengths and limitations and how different models may serve the supervisee and supervisor.

• Matching the model of supervision to the presenting practice concern or aspect of development; mapping to the pillars of advanced clinical practice.

Models of skills acquisition

• Developing critical awareness of different models of skills acquisition; their strengths and limitations and how different models may serve the supervisee and supervisor.
• Appraising models of skills acquisition in relation to different aspects of development aligned to the pillars of advanced clinical practice.

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Footnotes