Exploring the different terms used in supervision

This section aims to define the terms that the BDA uses for supervision, alongside a description of purpose. This should aid practitioners in considering the type of supervision they require and allow a shared understanding when approaching supervision sessions.  

Practice and clinical supervision   - These terms are often used interchangeably and are used here to describe the same thing. The BDA uses the term ‘practice supervision’ rather than ‘clinical supervision’ to ensure inclusivity of the whole of the dietetic workforce. Clinical supervision may align more with those who deliver clinical care or work within NHS services, but many dietitians will be a ‘practising’ dietitian, even if they do not deliver clinical care. For example, a dietitian working in academia as a lecturer for a pre-registration dietetic programme. As such, using the term practice, rather than clinical, recognises this. Practice supervision is also the term used by the HCPC with the following definition;

“…supervision is a process of professional learning and development that enables individuals to reflect on and develop their knowledge, skills, and competence, through agreed and regular support with another professional” (HCPC, 2021¹)

Purpose of practice supervision - Practice supervision is about supporting and enhancing practice, by enabling a person to reflect upon and review their work. It should take place on a regular basis (see Frequency of supervision), to enable continued support. Unlike management supervision, practice supervision should be led by the supervisee so that they can identify individual training and development needs. It does not need to be facilitated by a supervisor working at a higher level, but they do need to be competent to provide the supervision and have the relevant skills qualifications and knowledge².  In most cases, they do not need to be from the same professional background*, but they must still understand a dietitian’s scope of practice and delegate to another supervisor where necessary.

Practice supervision aims to:

• establish a confidential learning environment with guided reflective practice that allows the individual to learn from positive and challenging experiences
• enable a continuous improvement approach by supporting practitioners to discuss areas of their work or service that they feel are both effective and less effective
• assist practitioners in reflection to narrow the gap between theory and practice. This exercise may use recognised reflection models, such as Gibbs Reflective Cycle³.
• support CPD by helping to identify and respond to any learning needs which will help a practitioner ensure that their skills and knowledge are up to date
• reflect on professional issues which may be causing concerns, with an aim to promote own health and well-being, reduce stress and risk of burnout and improve service-user experience
• assist practitioners in ensuring their practice is evidence-based
• promote confidence within practice
• Provide a space to discuss and reflect on complex cases, including safeguarding discussions.
• Support practitioners to maintain safe practice within their scope and adhere to the HCPC professional standards.

*Within mental health settings, such as eating disorders and CAMHS, the quality standards⁴ recommend that supervision is delivered by someone from the same profession with appropriate clinical experience and qualifications. As such, the BDA position is that dietitians working in these environments should receive practice supervision by a suitably experienced dietitian.

Management supervision – Is usually conducted by someone in a position of authority who may or may not be working at a higher level. They may have line management accountability for the supervisee and so this supervision may also encompass appraisal and performance review. They may or may not be from the same professional background. This supervision, although still collaborative, is more likely to be led by the supervisor.

Purpose of management supervision – Management supervision may be more focussed around service needs and the contribution that the supervisee plays in this. It may be used to formulate job plans, agree annual leave and sickness monitoring, discuss recruitment, review mandatory training compliance, discuss caseloads, and risk assessments. It may also include personal matters by agreement, such as personal concerns that may require management support. An example may be if an individual requires a temporary adjustment to their working pattern.

Management supervision aims to:

• support practitioners to adhere to the HCPC professional standards
• enable practitioners to meet their formal appraisal objectives by collaboratively establishing personal development plans that identify and meet their development needs
• monitor progress collaboratively and identify professional development needs in relation to service delivery
• provide advice on managing key performance indicators, caseloads, and issues that may cause problems in the day-to-day functioning of a service, such as in planning annual leave and other absence
• Ensure practitioners are aware of the expectations within their job description and enable practitioners to fulfil these.

Restorative supervision - Aims to support the needs of practitioners working with clinically complex caseloads or in roles which are emotionally demanding and require difficult decision making. Examples within the dietetic workforce could include working in mental health settings or with terminally ill people. Most practitioners at some point in their career will work with people experiencing psychological distress. Restorative supervision provides a place to explore this to ensure that unspoken feelings do not impact on your wellbeing.  

Restorative supervision can be facilitated by a dietitian suitably trained with appropriate counselling and reflective skills. It can be of benefit to receive supervision from a clinical psychologist (if available) as their skillset is focussed on creating a safe space for discussion and reflection which can be particularly valuable for this process.

Purpose of restorative supervision – The predominant purpose and function of restorative supervision is that of supporting people with the emotional demands of their role. It is well documented⁵ that when practitioners undertake complex clinical work, they may experience anxiety, fear or stress. This can lead to compassion fatigue⁶ and burnout. It is for this reason that restorative supervision aims to support practitioners to process these feelings that then allow the focus to shift to identify solutions that develop and preserve resilience.  It may be, for some practitioners, that this restorative function is met through existing practice or management supervision sessions. In some specialist areas, restorative supervision may be needed on a regular basis.    

Restorative supervision aims to:

• build up compassionate resilience, which can support those working in roles where they are experiencing significant emotional demand
• reduce stress and burnout and increase compassion satisfaction
• have an immediate positive impact on the well-being of staff

These definitions demonstrate that each type of supervision has a distinct purpose, therefore a practitioner may need to link in with different supervisors to keep these elements separate. This will enable a practitioner to openly reflect and improve practice while being able to maintain and distinguish clear boundaries. If it is not possible for practice, management, and restorative supervision to be delivered by different people, there should be clear communication between the supervisor and supervisee about the nature of the session to ensure transparency and shared understanding of purpose.   

Informal supervision – Also termed ‘professional support’ by HCPC, this is more focussed on everyday work practices. It is provided on an ad hoc and less formal basis and is unlikely to be with the named supervisor. It may be provided from a wide variety of people, groups, and sources.

Purpose of informal supervision – Informal supervision is essential to enable individuals to learn about the daily workplace practice and procedures through exchange of information and sharing of expertise. While practitioners and managers at all levels of experience benefit from this, it is particularly important for newly qualified practitioners (NQP), non-registered staff to aid delivery of delegated care, those new to an organisation/team/role and those working in isolation.  The nature of informal supervision – being ad hoc and not documented – may mean that it is not always recognised as supervision.

Informal supervision aims to:

• support practitioners in managing their day-to-day cases and workload
• reduce stress by providing means to discuss distressing or complex situations
• provide joint working opportunities through open discussion to identify where this would benefit the service user and practitioner(s)
• provide informal peer learning opportunities and peer support
• provide opportunities to access specialist advice where this is needed to support clinical judgement and decision making e.g. “can I run this scenario past you?” 

For informal supervision to be effective, services need to create a culture of openness and trust where individuals feel empowered to ask for support. There needs to be honest ‘open door policies’ so that individuals needing support do not feel that they are a burden to others. This is of the highest importance considering the sustained pressure experienced within health and care services over recent years and is key to retaining our workforce⁷.

One disadvantage of informal supervision, however, is that the time needed for considered discussion may not be held equally by both parties. Its impact should be sensitively monitored to ensure that accessing support to those in need does not negatively impact on those who provide it.   

As with all supervision, informal supervision needs to be confidential and non-judgmental.    

A few real-life scenarios are given below to highlight the difference between management, practice, restorative and informal supervision.

Example 1 – caseload management for inpatient wards

Management supervision – During your regular supervision session with your team leader, you are asked to discuss how you are coping with your caseload. This is important for the team leader to understand as there is a need to consider whether extra work can be distributed across the team because there are vacancies, and one person is on long-term sick leave. This discussion may relate to how your caseload compares to departmental standards or waiting times. It may consider what the identified Key Performance Indicators (KPI) are, what the BDA safe staffing document details and how the referral rate compares. You may then discuss your job plan and determine if there is scope for making changes, on a short-term basis while staffing is poor, to improve overall performance against the standards. You highlight to your line manager that you feel you are at capacity, and you discuss whether additional resources, such as an extra session with a dietetic support worker may be helpful.  As you are new to your current rotation and are currently supporting a dietetic learner, you agree that no changes will be made to your job plan, and this will be reviewed again at the next session. The agreed actions from this management supervision session are documented on your supervision template.

Practice supervision – As a newly qualified dietitian, your regular practice supervision session is with a more experienced dietitian. As practice supervision is led by the supervisee, you suggest that you would like to discuss caseload management. You reflect on how the high caseload expectation in your current rotation can sometimes make you feel overwhelmed and that you seem to struggle and worry about this more than others. This means that you often leave the office later than your finish time and you have sometimes been worrying about work at the weekend. You know that the caseload expectation for you is the same as your other colleagues, but you seem to worry about it more than them.

You find that sharing these feelings is helpful as your supervisor has constructively challenged and encouraged you to reflect on this scenario meaning you can generate solutions that may improve this situation. This discussion also helps you to identify that you seem to worry more about the caseload when there are high numbers of a certain type of referral so it may be that you have a learning need in this area. Your supervisor suggests that you may find it helpful to spend your next CPD session researching or shadowing a more experienced colleague to identify and address any gaps in knowledge and to see how their practice may differ to yours. You also agree that you will present a Case Based Discussion on this at your next supervision session. These agreed actions are documented on your supervision template to revisit at your next formal practice supervision session.

Informal supervision – While on the ward, you are asked to provide a feeding regimen for a new service user who has been transferred from the nearby mental health hospital. You are advised that they have met the criteria for compulsory admission and treatment under the Mental Health Act and that a nasogastric tube has been inserted for feeding. Whilst you are familiar with nasogastric tube feeding and regimens, you have never been involved in a situation where the treatment is compulsory. As such, you phone a more experienced dietetic colleague for advice. This support and guidance enable you to confidently put an appropriate care plan in place and means you will feel more comfortable if presented with this scenario in future. You may find that imposing this type of feeding on this service user has left you with uncomfortable feelings. This sort of scenario may be explored through restorative supervision that ensures unspoken feelings do not impact on your wellbeing or your decision making.

Example 2 - Transitional roles

Management supervision – Three months ago, you transitioned from a role in adult dietetics to paediatric dietetics. Your regular supervision session with your team leader is due and as you have been in your new role in paediatrics for 3 months, you are preparing for your initial performance review. You are asked to discuss how you are finding the transition into the new role which is important for the team leader to understand to establish if your job plan is appropriate. This discussion may highlight that more clinical activity needs to replace the dedicated time you were scheduled in your job plan for shadowing and self-directed learning in the first 3 months. Your team leader may highlight that you have a lot of outstanding annual leave to take before the end of the year which needs to be scheduled so that the new clinical activity can be booked around this. You may discuss that you have identified a specific CPD opportunity that would enable you to provide a better service for users. The agreed actions from this management supervision session are documented on your supervision template.

Practice supervision – Your regular practice supervision session is between yourself and an experienced paediatric dietitian. As practice supervision is led by the supervisee, you suggest that you would like to discuss the differences between working with adult and paediatric service users. You reflect on how challenging it can be to meet the expectations of both the service user and the parents/carers, especially for older children and that this was not something you had considered prior to moving into the role. You discuss that you are aware of how much social media influences some of your service users which you feel is different to working with adults.      

You find that sharing these feelings is helpful and your supervisor has encouraged and constructively challenged you to reflect on this scenario. This means you can generate solutions that may help you more easily manage your interactions with the service user and the parents /carers. You identify that spending time with a paediatric professional outside of your specialist area may help you to enhance your communication skills with parents and you therefore agree to schedule this into your next CPD session. These agreed actions are documented on your supervision template to revisit at your next formal practice supervision session.

Informal supervision – While attempting a telephone review, a parent becomes verbally abusive and won’t allow you to speak with the service user. They then hang up the telephone, you call back immediately but there is no answer. You have never experienced this before and therefore go into the office to discuss with one of your colleagues. As well as providing informal peer support, this provides you with guidance that allows you to consider the options available to you so that you can take the appropriate next steps.  You may find that being verbally abused in this way has left you with uncomfortable feelings. This sort of scenario may be explored through restorative supervision that ensure unspoken feelings do not impact on your well-being.