Journal of Advanced Nursing, 1998, 27, 379–382

Evaluating the efficacy of reflective practicewithin the context of clinical supervision

John Fowler MA BA RGN RMN DipN Cert Ed RNT

Senior Lecturer

and Mel Chevannes PhD MA BA(Hons) RGN RHV RM Teachers Cert RHVT

Head of the Department of Nursing & Midwifery, DeMontfort University, Leicester,England

Accepted for publication 2 February 1997

FOWLER J. & CHEVANNES M. (1998) Journal of Advanced Nursing 27, 379–382Evaluating the efficacy of reflective practice within the context of clinicalsupervisionThis paper explores the efficacy of reflective practice within the context ofclinical supervision. It examines some potential limitations that reflectivepractice has within the context of clinical supervision drawing upon theliterature and the early stages of the author’s empirical work. It concludes thatwhilst there is considerable congruence in the use of reflective practice withinclinical supervision sessions, there are potential disadvantages in making theassumption that reflective practice should be an integral part of all forms ofclinical supervision.

Keywords: reflective practice, clinical supervision, reflection

will enable these functions. Chris Johns (1993) who hasTRAINED MINDS

been central in raising the nursing profession’s awarenessof reflection within nursing practice says that the milieu

Through ambition alone you cannot reach your goal. You mustwhere reflective practice is facilitated is called pro-

have assistance from trained minds. Minds who like you cravedfessional supervision.

knowledge and found it.Many years ago Peplau (1927, 1964) identified that

Hildegard Peplau (1927)nurses had a need for clinical supervision. She talkedimplicitly about reflective practice as part of clinical super-The United Kingdom Central Council for Nursing,

Midwifery and Health Visiting (UKCC 1996) in its pos- vision, stating that the staff nurse should come preparedwith notes or verbatim data and that the supervisee shouldition paper on clinical supervision identifies reflection as

a key process between the practitioner and the super- do most of the talking. The aim of the supervisor was totry to perceive the interactions in the context of the situ-visor. This seems logical and indeed an ideal way to

harness the much talked about but possibly little prac- ation and to suggest alternative modes of responding.Darling’s (1984) USA work on mentoring fits comfortablytised technique of reflection. Magi Fisher (1996), in her

discussion of reflective practice in clinical supervision, with the United Kingdom’s current perception of clinicalsupervision. She developed the ‘Darling MMP —stresses the need for reflection to result in the develop-

ment of practice. She suggests that if the three functions Measuring Mentoring Potential’ which identifies 14characteristics in an ideal mentor. Four of these character-of clinical supervision — education, support and manage-

ment — are also the focus of reflection, then reflection istics come under the umbrella of reflective skills, i.e. feed-back giver, eye opener, challenger and idea bouncer. Thisperspective is echoed by the former lead officer at theCorrespondence: John Fowler, Department of Health & ContinuingDepartment of Health, England, Professor Veronica Bishop,Professional Studies, DeMontfort University, Charles Frears Campus, 266

London Road, Leicester LE2 1RQ, England. who identified similar reflective skills as part of her ‘key

379© 1998 Blackwell Science Ltd

J. Fowler and M. Chevannes

ingredients’ for the process of clinical supervision As clinical supervision becomes available for allnursing and health visiting staff within the UK as(Bishop 1994).recommended in the UKCC’s policy document (UKCC1996), what are the implications for this widespread acc-

REFLECTIVE PRACTICEeptance of the compatibility of reflection and clinicalsupervision?The above references to reflective practice within clinical

supervision are not isolated examples taken from the lit-erature. They are a representative view of the considerableliterature on clinical supervision. They are evidence that

POSSIBLE LIMITATIONS OF ACCEPTINGthe interplay of reflective practice and clinical supervision

REFLECTION AS AN INTEGRAL PART OFis very strong and runs as a theme throughout much of the

CLINICAL SUPERVISIONliterature. Whilst being acknowledged as a significant partof clinical supervision, reflection is not being proposed as Chris Johns has said that, ‘the milieu where reflective prac-

tice is facilitated is called professional supervision’ ( Johnsthe sole happening within the process. Darling includesother characteristics such as teacher, door opener, career 1993 p. 11). This seems logical and appropriate. What

Johns is not saying, however, is that professional super-counsellor and energizer (Darling 1984).Bishop (1994) also includes wider activities such as net- vision should always facilitate reflective practice. This

subtle difference is an important one. In a similar wayworking and collaboration. However, whilst not being pro-posed as the sole happening within clinical supervision, Friedman and Marr’s supervisory model of professional

competence (1995) proposes the practitioner seekingreflection does seem to be seen as an important and integralpart of supervision. The compatibility of reflection and meaning from experience and imposing meaning on events

in practice, stating that if this can be harnessed throughclinical supervision appears to be unquestioned within theliterature. If clinical supervision is seen as a formal system the model of clinical supervision then the capacity for

pushing forward professional boundaries is considerable.then reflection appears to be its enabling process.Again, what is being proposed is that the reflection onpractice is harnessed by clinical supervision. They are not

CHARACTERISTICS OF CLINICALsaying that clinical supervision should always utilize

SUPERVISIONreflective practice.

Clinical supervision is proposed as a way of ‘harnessing’Based upon Proctor’s (undated) normative, formative, res-torative characteristic of clinical supervision, the interplay reflective practice, but this is not to say that reflective

practice should always be an integral part of clinicalof reflective practice would appear to be as shown inFigure 1. supervision. This distinction is important. For many clin-

icians reflection on and in practice is a useful and even anemancipatory process. But maybe for some it is not sucha useful process. For these, albeit a minority, it may beinappropriate or undesirable. Why might this be so?

Atkins & Murphy (1993), in their review of the literatureon reflection, say that reflection must involve the self andmust lead to a changed perspective. This is echoed bySnowball who say that, ‘It is clear in the literature thatinvolvement of self is a crucial element of the reflectiveprocess’ (Snowball et al. 1994 p. 1235). They go on to saythat the individual needs to be minimally defensive andwilling to work in collaboration with others. Whilst thismight be an ideal to which all practitioners should attainit is one from the author’s experience that not all staffdo attain.

Whilst some staff seem to be open and welcoming tothe concept of reflective practice with its involvement ofthe self, others seem to view this as unhelpful andalien to their way of thinking. The author is not proposingthat either of these views is better than the other,simply that both extremes and variations on them doseem to exist within the general population of

Reflection

NORMATIVE

(Quality)

CLINICAL SUPERVISION

FORMATIVE

(Development)

RESTORATIVE

(Support)

Reflection Reflection

Figure 1 Interplay of reflective practice and clinical supervision. practitioners.

380 © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 379–382

Reflective practice

groups of clinical staff have regarding the possible intro-REFLECTIONduction of formal clinical supervision into their clinicalarea. The following results are from the qualified nursingIf a model of clinical supervision which has reflection as

an integral part is offered or even imposed on people for grades.Twenty-nine per cent of respondents felt that they cur-whom that style is inappropriate then clinical supervision

is likely to be avoided or any outcomes minimalized. It rently worked within a structure whereby they had anidentified clinical supervisor and that the aims of clinicalmay be that a supervisor who is skilled and experienced

in reflective techniques could direct the supervisory ses- supervision were clearly identified. Slightly more felt thatthey had access to various aspects of clinical supervisionsion so that the supervisees value and appreciate the

experience even though it is not one that fits happily with (as defined by Proctor’s characteristics of normative, for-mative and restorative). Fifty-one per cent identified withtheir temperament.

A further reservation that the author has to the unques- a normative aspect of clinical supervision, 44% with for-mative and 59% with restorative. The respondents expec-tioning acceptance of reflection as a tool within clinical

supervision comes from the work of Patrica Benner (1982). tations of clinical supervision appeared to be high, anoverwhelmingly majority of all respondents (90%) viewedIn her work on ‘novice to expert’ Benner identifies ‘begin-

ners’ as having no experience with the situations in which clinical supervision as not being a waste of time. Therewas also an expectation that clinical supervision wouldthey are expected to perform tasks. The teaching that they

receive therefore has to take account of their lack of experi- take on a reflective nature: 89% thought that it would helpthem focus on and improve patient care, 91% thought itence. However, once the person begins to practice at com-

petent and proficient levels then Benner says they see would help them focus on their strengths and 90% thoughtit would help them focus on their weaknesses.things in terms of long-term goals and have a holistic pic-

ture of practice. They learn best by reflecting on case stud- Whereas 68% of respondents felt that clinical super-vision would reduce the stress they experience at work,ies. ‘By assisting the expert to describe clinical situations

where his or her interventions made a difference, some of 23% thought that it would increase it. The analysis is attoo early a stage yet to identify why they felt it wouldthe knowledge embedded in the expert’s practice becomes

visible’ (Benner 1982 p. 406). increase stress and if this was for all grades of staff or justfor some. It is also not possible at this stage to predict ifThus for the person with little or no experience reflec-

tion may be an inappropriate and frustrating method. A the increase in stress anticipated as a result of clinicalsupervision (by the 23%) would have a motivating andmore efficient use of time for this type of practitioner may

be a more directive teaching programme of those areas he positive effect or a negative effect. It is, however, evidentthat not all staff have the same expectations of the effects‘doesn’t know he doesn’t know’. For the person with clini-

cal experience reflection is the way to deepen their knowl- that clinical supervision will have upon their stress levels.The initial conclusion is that staff are viewing theedge and in terms of Benner’s expert, to draw out and

make visible some of their knowledge. implementation of clinical supervision positively and seeit as a way of reflecting upon and influencing patient care.How does this interpretation of the literature relate to

practitioners views and expectations of clinical super- There are, however, some concerns by some staff regardingthe additional stress that clinical supervision may bring.vision? In the first stage of an evaluative research study

the author carried out a survey examining nurses’ viewsand expectations regarding clinical supervision. The fol-

CONCLUSIONSlowing section summarizes the respondents’ views regard-ing their expectations and some of the reservations that It is evident from the policy documents, the general opi-

nion of the literature and the early stages of the author’sthey expressed.empirical work that there is a high degree of compatibilitybetween reflective practice and clinical supervision. Those

PRACTITIONERS’ EXPECTATIONSpractitioners coming from a clinical supervision perspec-tive tend to see reflective practice as a process within clini-A stratified random sample of nursing grades A–H was

developed across all the National Health Authority Trusts cal supervision and those coming from a more traditionalreflective practice perspective tend to see clinical super-in one health authority (approximately 25 staff in each

grade in each trust for all of the five NHS trusts in one vision as a structure or environment for reflective practice.Whilst this compatibility seems justifiably high a notehealth authority); 1081 questionnaires were sent out, 558

were returned giving a 52% response rate. The question- of caution should be introduced. Reflective practice maybe part of clinical supervision but it need not be the mainnaire addressed two research objectives, firstly to identify

current practices regarding formal and informal clinical focus. The strength of clinical supervision is that themodel of application can and should be developed to meetsupervision within one health authority and secondly to

identify concerns, needs and expectations that particular the specific needs of groups and individuals. For some and

381© 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 379–382

J. Fowler and M. Chevannes

Darling L. (1984) What do nurses want in a mentor? The Journalit could be many practitioners, their needs may best beof Nursing Administration 14(10), 42–44.accomplished by using reflective practice as an integral

Fisher M. (1996) Using reflective practice in clinical supervision.part of the process. However, for some this might not beProfessional Nurse 11(7), 443–444.appropriate and may even be detrimental. If this were to

Fowler J. (1996) How to use models of clinical supervision inbe the only ‘model’ of clinical supervision that was onpractice. Nursing Standard 10(29), 42–47.

offer to them then it may lead to a significant number ofFriedman S. & Marr J. (1995) A supervisory model of professional

practitioners declining or withdrawing from clinical competence; a joint service/education initiative. Nursesupervision. Education Today 15, 239–244.

Clinical supervision therefore needs to be structured to Johns C. (1993) Professional supervision. Journal of Nursingmeet individual needs (Fowler 1996) rather than imposing Management 1, 9–18.

Peplau H. (1927 & 1964) In Hildegard Peplau. Selected Works.a preformed model or structure on individuals. The expec-Interpersonal Theory in Nursing (O’Toole A. & Welt S. eds,tations of the profession are high but neither clinical super-1994) MacMillan, London.vision nor reflective practice are panaceas. It remains to

Proctor B. (Undated) A co-operative exercise in accountability. Inbe seen, hopefully through evaluative research, if theseEnabling and Ensuring — Supervision in Practice (Marken M.expectations will be met.& Payne M. eds), National Youth Bureau Council for Education& Training in Youth & Community Work, Leicester.

Snowball J., Ross K. & Murphy K. (1994) Illuminating dissertationReferencessupervision through reflection. Journal of Advanced Nursing

Atkins S. & Murphy K. (1993) Reflection: a review of the literature. 19, 1234–1246.Journal of Advanced Nursing 18, 1188–1192. UKCC (1996) Policy Statement on Clinical Supervision for

Benner P. (1982) Novice to expert. American Journal of Nursing Nursing and Health Visiting United Kingdom Central CouncilMarch 402–407. for Nursing, Midwifery & Health Visiting, London.

Bishop V. (1994) Clinical supervision for an accountable pro-fession. Nursing Times 90(39), 35–37.

382 © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 379–382