Value-added care

11 May 2017

Jo Ward and Janet Durrans describe a project to implement integrated clinical supervision at Cheshire and Wirral Partnership NHS Foundation Trust, which has resulted in better outcomes for staff and patients alike.

The district nursing workforce is under increasing pressure as the number of older people needing care within our communities who have long-term conditions rises. And the care being delivered is often complex and can be challenging to deliver.

A range of factors is causing this rise in demand: the population is ageing but these are not necessarily healthy years. Data from Cheshire West and Chester in 2014 suggests that people living in the area will spend between 14 and 16.3 years living in ‘not so good’ health.

But it could be argued that this figure is likely to be significantly higher in the most deprived wards within the borough, which has lower life expectancy.

The number of people in the community with multiple or long-term complex conditions is increasing constantly. Life expectancy in some of the wards within Chester and Cheshire West is extremely poor, with clear health inequalities between wards that are often in close proximity.

Data from the local health profile in 2015 showed that, across the borough’s 46 wards, there is a difference of 10.1 years in life expectancy in males and 7.9 years in females. The borough faces continued challenges to reduce rates of circulatory diseases and cancer, while deaths from liver disease and lung cancer have been increasing within Cheshire’s most deprived communities. 

Complex needs

Against this backdrop, the community nursing and allied healthcare workforce is tasked with delivering complex care to some of the area’s most vulnerable individuals. 

Such episodes of care are often delivered when a patient’s illness is traumatic. And the expectation for teams to meet the rise in demand and strive for continuous quality improvement is a key measure for commissioner targets. 

A recent report by The King’s Fund (2016) highlights the impact of the pressures on quality of care on the workforce. It explores the dwindling numbers of community nurses and the detrimental effect this is having on staff health and wellbeing.

It can be exceptionally hard for practitioners to make time to reflect on the care they deliver when patient demand is surging. But doing so is as important as the physical care being delivered and is essential for staff’s resilience and emotional health and wellbeing. The need to have regular clinical supervision and build a culture of reflective practice is a key part of working more effectively together as an integrated team (Carpenter et al, 2012). 

Integrated approach

The need to ensure clinical supervision is a regular feature in practice has been widely recognised. At Cheshire and Wirral Partnership (CWP) Trust, the supervision aim is to build a culture of integrated clinical supervision and values-based reflective practice. To achieve this cultural shift, each community care team has divided staff into mixed-discipline supervision groups of between five and eight staff. 

If teams don’t carve out regular clinical supervision reflection into the fabric of who they are, they risk outcomes such as raised sickness levels, staff burnout, recruitment and retention issues, team dynamic issues and increased risk around clinical governance. The model enables professional groups to explore differing roles and responsibilities in a safe and confidential context as part of an integrated team.

Integrated values-based supervision doesn’t seek to replace individual or management supervision; it’s about strengthening the culture within teams to work together in the best interests of the patient. The trust received support from William Jackson at Edge Hill University and Ian Hall from Crossley Hall Associates to create a number of reflective practice templates that staff could use in supervision sessions.

The templates ensure the sessions remain patient focused, and each closes with a set of actions. They were developed to follow both Gibbs’ (1988) and Driscoll’s (2006) reflective practice models, enabling practitioners to explore thoughts, feelings, behaviours, what worked well or needs improving and what it means to individuals or the integrated team. And at the end of each session the facilitator re-engages the group with the values of care, compassion, competence, communication, courage and commitment. This is particularly empowering for staff. 

‘Deep dive’ project

Last year, CWP Trust embarked on a journey to strengthen clinical supervision activity within physical health integrated teams. The journey is ongoing in the form of a commissioned project, in which targeted support is being given to community care and specialist teams to build an integrated reflective practice culture.

The trust commissioned a ‘deep dive’ review that explored the challenges within district nursing. One piece of work to emerge from this process was the need to review clinical supervision. The brief was to embed a values-based model into all of the trust’s community care and specialist teams, including the continence, tissue viability, end-of-life, Parkinson’s and out-of-hours district nursing services. A series of one-hour clinical supervision workshops was designed to engage staff and build interest and motivation. Following the workshops, each team is supported to ‘road-test’ the concept in small integrated groups.

The project continues to be well received by staff, who are keen to build a supportive framework into their teams. While the work has encountered challenges due to surging demands on the community teams, it has nonetheless been evaluated positively.

Staff are recognising the benefits of learning from each other and report feeling positive that the sessions can make a difference to patients and their own health and wellbeing. And having a mechanism for action-based sessions helps empower staff to have a voice and challenge practice at a time when resilience is shown to be poor.

Clinical supervision: key messages

  • Embedding an integrated clinical supervision model into community care teams is challenging in the current climate
  • Teams need time to develop a clear vision of roles and responsibilities
  • Integrated clinical supervision needs to be implemented carefully
  • Clinical supervision is essential to the whole community care team if a clear vision and focus is to be reached and maintained around integrated working
  • Group-based clinical supervision also enables ‘temperature checks’ on staff resilience levels
  • Trusts should look beyond the usual data reporting system for clinical supervision to capture a qualitative picture of reflective practice and innovation, and consider exploring staff resilience levels regularly within local teams


Carpenter J, Webb C, Bostock L, Coomber C. (2012) SCIE Research briefing 43: effective supervision in social work and social care. 
See: scie.org.uk/publications/briefings/briefing43 (accessed 26 April 2017).

Driscoll J. (2006) Practising clinical supervision: a reflective approach for healthcare professionals. Baillière-Tindall: Kent.

Gibbs G. (1988) Learning by doing: a guide to teaching and learning methods. FEU: London

The King’s Fund. (2016). Understanding quality in district nursing services. See: kingsfund.org.uk/publications/quality-district-nursing (accessed 26 April 2017).

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