How to use clinical supervision to increase the use of evidence-based practice
Clinical supervision affords clinicans and planners the time and application opportunity to engage with research and evidence that can inform professional practice in the day-to-day environment, argue Emily Steventon and colleagues.
In the NHS there is a longstanding preoccupation with ensuring that the content and delivery of care is based on high-quality research. Using the knowledge from scientific studies in practice holds promise for increasing the quality of care and enhancing treatment outcomes.
Clinicians and healthcare planners who want to improve the quality and efficiency of healthcare services should be guided by research evidence. This is especially important in the current economic climate where research evidence may play a key role in helping the NHS to respond to the challenge of improving quality, while simultaneously finding efficiencies.
In the NHS and social care sector individual practitioners are encouraged to search for evidence independently. This responsibility is supported by resources such as NHS Evidence, which have ensured that high-quality research evidence is increasingly accessible to practitioners.
Individual health professionals are expected to identify and keep informed about the latest research developments, which are then used to inform day-to-day professional practice.
But is this actually happening in reality? This is the question we hoped to address by evaluating how interprofessional community health practitioners were accessing and using research evidence in their everyday practice. The project was undertaken 2009-2010 in collaboration with the Health Services Management Centre at the University of Birmingham.
Qualitative interviews with 21 practitioners were undertaken to ascertain awareness of evidence-based practice and how staff were engaging with this process. Despite a clear understanding of what evidence-based practice (EBP) is and its importance to quality care, the ability to identify examples in individuals’ practice was lacking.
This is not surprising when we consider that one of the biggest barriers to engaging in evidence-based practice, and the groundwork it requires, is time. Similar to evidence from research studies our project identified that clinical commitments took priority over evidence-based activities for those in front-line roles.
It is generally recognised that up to two decades may pass before the findings of original research become part of routine clinical practice. The challenge is how to overcome this time lag.
A wide range of initiatives exist that aim to improve the use of research by practitioners delivering public services. We know that access to relevant information resources such as NHS Evidence are important, but on their own they are likely to have limited success unless there is a commitment to repeatedly engage with these resources.
This is where the time barrier is impacting the most. The need to define strategies to facilitate the use of research evidence in health care practice is vital to ensure the translation of the best available evidence in everyday practice.
What can we do to overcome the time barrier? Findings from our project indicated that those in specialist or educational roles were able to “make time” to engage in evidence-based activities. But that still leaves those in frontline roles falling by the evidence-based practice wayside.
Although staff in front-line roles weren’t as readily engaging in evidence-based practice they were all taking part in clinical supervision. This got us thinking about a much more transparent role for clinical supervision in facilitating evidence-based practice.
How can clinical supervision help? Clinical supervision has long been recognised as a valuable and necessary means of facilitating personal and professional development for individuals working in a clinical setting. The evidence-based healthcare movement encourages a questioning and reflective approach to clinical practice and emphasises the importance of lifelong learning; an aim which is synonymous with clinical supervision.
How, then, might we harness the potential of clinical supervision? A wide range of initiatives exist that aim to improve the use of research by practitioners delivering public services. However, as yet no model has been credited with comprehensively solving the research-practice gap. This is where clinical supervision holds promise. As well as Registered Nurses, all Allied Health Professionals (including occupational therapists, physiotherapists, dietitians, speech and language therapists and podiatrists) are expected to have regular clinical supervision.
Clinical supervision in the NHS is an integral part of professional development, attendance is mandatory and it is enforced through trust policies. Consequently, because clinical supervision is “protected” time it may be an appropriate means through which to overcome the time barrier.
How might we apply this? Inadequate organisational and peer support and insufficient knowledge and skills make it difficult for professionals to search for and interpret evidence. Excellence in clinical supervision could provide greater adherence to evidence-based practice endeavours. To this end, specific recommendations arose from our project:
- A renewed focus on trust-wide clinical supervision policies for all clinical staff;
- Management buy-in and implementation of clinical supervision policies;
- Undertaking clinical audit to ensure that clinical supervision is maintained and monitored;
- Embedding clinical supervision in the appraisal process;
- Ensuring clinical supervision remains protected time;
- A more transparent role for evidence review in clinical supervision;
- Defined examples of opportunities for evidence review (e.g. journal clubs).
Perhaps the most significant recommendation is the need to define what constitutes evidence-based activities and how these might be conducted in clinical supervision. Many NHS trusts will acknowledge the promotion of evidence-based practice as a key aim in clinical supervision policies, however details on ground rules and supervisor/supervisee roles and responsibilities are often lacking.
What about a potential application? Lack of adherence to NICE guidelines is a point for continued debate. Non-compliance with guidelines drawn up following the review of evidence has implications in the quality and effectiveness of care patients receive. Lack of application of guidelines in practice indicates that support to improve the translation of knowledge may be needed.
If time is a barrier to accessing and using evidence then the protected time of clinical supervision may allow health professionals the opportunity to read and digest NICE guidelines. Through clinical supervision it may be possible to move from a change in knowledge to a change in practice.
There are potentially several limitations to a clinical supervision model for research translation and the suggested utility of clinical supervision is quite tentative. Clinical supervision appears to be highly valued, yet is paradoxically under-developed. It’s certainly something of a moveable feast.
Various models of clinical supervision (educational, professional, pastoral) and modes of delivery (group, one-to-one) mean the quality and consistency of supervision is variable. Although ideally it is a structured undertaking, we know that some clinical supervision occurs on a more ad-hoc basis as clinical issues arise and these may not be the most befitting platform for evidence-based activities.
It’s okay suggesting that everyone should be actively engaging in evidence-based activities in clinical supervision but there’s the danger that without training in critical appraisal skills ambiguous evidence could be misused. If we can address such constraints, clinical supervision may help clinical staff meet the demands of evidence-based practice.
There is no magic bullet, no single solution to the transfer of evidence into practice, however, for health professionals who are working in the NHS era of “more for less” and for whom time is limited, the protected time afforded by clinical supervision may be key.
Transferring this message to those responsible for delivering and those who are the target of supervision policies is the challenge that lies ahead. The reasonable goal of science-informed practice is now within our reach.