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Safeguarding supervision: on the front line

07 November 2019

Ann Guindi, Alex Hassett and Margie Callanan explored the factors that contribute to effective safeguarding supervision in community nursing.


Author: Ann Guindi, PhD Student Canterbury Christ Church University

Co-Authors: Professor Alex Hassett, Principal Lecturer and Senior Consultant, Salomons Centre for Applied Psychology, Canterbury Christ Church University and Professor Margie Callanan, Programme Director of Clinical Psychology Doctorate, Director of Salomons Institute for Applied Psychology, Salomons Centre for Applied Psychology, Canterbury Christ Church University.

Email: a.guindi@nhs.net


Research summary

  • The researchers, at Canterbury Christ Church University, offer an update to the review carried out by Botham (2013) on clinical supervision within child protection, but it focuses solely on perspectives of frontline nursing professionals, and also more explicitly differentiates between clinical and safeguarding supervision.
  • It explores what factors contribute to effective safeguarding supervision, what frontline practitioners feel is helpful and unhelpful, and how the supervisory relationship assists or detracts from the process.
  • Papers were selected from peer-review journals of frontline practitioners working in the community dating from 2000 onwards. Midwives, counsellors and psychotherapists were excluded.
  • Searches were conducted from five databases, and additional sources – the Royal College of Nursing, Nursing Times and Nursing Standard.
  • A systemised approach was used, collating the findings from 11 papers from January 2000 to January 2019, brought together in a thematic synthesis.

Abstract

This review is an update on Botham’s (2013) review of clinical supervision in child protection but with two clear differences: the focus of this paper is primarily on safeguarding supervision and explores the views of frontline nurses only. The aim was to explore what factors contribute to effective safeguarding supervision. A systemised approach was used, collating the findings from eleven papers from January 2000 to January 2019 brought together in a thematic synthesis. This paper analysis suggests that there are factors deemed helpful and unhelpful in the safeguarding supervision process which can also be applied to the supervisory relationship. However, given some of the methodological limitations of the research reviewed one needs to be cautious in drawing conclusions from the current research. This review concludes that there is a need for more evidence in this area to see what makes safeguarding supervision effective. Furthermore, it is also important that research begins to establish whether safeguarding supervision does help in achieving better outcomes for children in keeping them safe.   

Keywords: safeguarding supervision, frontline nurses and supervisory relationship


Introduction

This review will focus on the perspectives of front-line nursing professionals working in child protection and how they perceive the safeguarding supervision process. Safeguarding supervision within community nursing is still a relatively new term in that it has only appeared in the literature in the last 15 years within a health context (Green-Lister and Crisp, 2005; Hall, 2007; White 2008; Botham, 2013; Hackett, 2013; Jarrett and Barlow, 2014; Rooke, 2015; Wallbank and Wonnacott, 2015; Smikle, 2017; Warren, 2018 and Little et al, 2018). ). It was not until 2014 that the Royal College of Nursing (RCN) included safeguarding supervision for the first time in their position paper ‘Safeguarding Children and Young People - every nurse’s responsibility’ (RCN, 2014). However, this review found that the ‘clinical’ and ‘safeguarding’ in supervision terms were still being used interchangeably.

Clinical supervision in nursing is well researched and written about within practice for the past 20 years, but the focus is on ‘clinical’ hands-on practice and delivery of care (Cutcliffe et al, 2001 and Bond and Holland, 1998). Many of the current definitions for supervision stem from other professions. The Care Quality Commission’s (2013) guidance for supporting effective clinical supervision is taken from the Skills for Care (2007) definition, and defines it as ‘an accountable process which supports, assures and develops the knowledge skills and values of a group or team’ (CQC, 2013). This definition does not focus on any aspect of safeguarding supervision and has no mention of how frontline practitioners risk assess and protect children from harm.

Safeguarding supervision has a very different focus to clinical supervision and is a multi-factorial process, with many elements that need to be considered involving the child, family, practitioner, supervisor, supervisee and the organisation. Thus, making it a very complex process.

To date there is still no universally accepted definition in practice for health professionals working with children for ‘safeguarding supervision’.  Smikle (2017) did however put forward the following definition:

‘Safeguarding supervision is a facilitative process that enables the supervisor and supervisee to reflect on, scrutinise, challenge and evaluate the work undertaken. This includes assessing risk and protective factors for the child in question as well as the strengths and areas for development of the practitioner. The context should be an environment in which the supervisee receives appropriate emotional support’ (Smikle, 2017).

This definition incorporates many elements to the supervision process such as reflection, development and the supportive nature of the supervision process for the nurse, but also focuses on the child in assessing risk. There is now clearer acknowledgment on safeguarding supervision being child-centred in how to protect the child, which is not the case in clinical supervision.

More recently Little et al (2018) put forward an alternative definition:

‘A process by which safeguarding nurse specialists work with case-holding health visitors and school nurses who are responsible for the healthcare of children who have been the focus of a safeguarding review’ (Little et al, 2018).

This review will assess to what extent that these definitions are reflected in the perspectives of front-line professionals within their practice and experience of safeguarding supervision.


Nursing and safeguarding supervision

Nurses are often the first point of contact and at times the only point of contact for families (Hackett, 2013). Therefore, it is imperative that nurses are adequately equipped to recognise and act on any safeguarding issues and refer on to social care. Hall (2007) suggests in her findings that ‘safeguarding supervision is perceived as essential by front-line practitioners’.

However, there is little evidence to suggest whether safeguarding supervision makes any difference to families in keeping children safe from harm. As it is an accepted fact that many of the families discussed during safeguarding supervision are already known to social care and on a Child Protection Plan as outlined above by Little et al (2018), it could therefore be argued that the children are more protected from harm in that social care are aware of the risks to the child. This concept was first highlighted by Wallbank and Wonnacott (2015).

Laming (2003), in his inquiry into the death of Victoria Climbié, suggests that a lack of supervision within the social work profession was a contributing factor in her death (Laming, 2003 and 2009). The child becomes unseen and unheard. The child’s needs are paramount, as stated in the ‘Welfare Principle’ of ‘The Children Act’. There was a refocus on this principle following Lord Laming’s Inquiry (2003). The Government’s response to this inquiry was to publish a key document ‘Every Child Matters’ (HM Treasury, 2003), with a focus on the five outcomes for children. Both these documents led to the introduction of ‘The Children Act’ 2004. This child-centred approach was endorsed by Munro (2011) advocating more focus on hearing the voice of the child.

The Royal College of Nursing (RCN, 2014) has issued the following guidance on safeguarding supervision: “Regular high-quality safeguarding supervision is an essential element of effective arrangements to safeguard children”. They also suggest that safeguarding supervision should be regular, on a monthly to six-weekly basis, to be effective.

This paper is offering an update to the review carried out by Botham (2013) on clinical supervision within child protection. This review differs in that it will focus solely on nurses and aims to be more explicit in the differences between clinical and safeguarding supervision as outlined previously. It has been suggested by Botham (2013) that clinical and safeguarding supervision are synonymous. However, given the difference in focus on keeping the child safe it can be argued that these are two different aspects of practice which require very different skill sets.


Aim

  • The aim of this review is to explore what factors contribute to effective safeguarding supervision.
  • What do front-line practitioners feel is helpful and unhelpful in the process?
  • How does the supervisory relationship assist or detract from the process?

Search Strategy/Methodology

Papers were selected from peer review journals of frontline practitioners working in the community dating from 2000 onwards. Midwives, counsellors and psychotherapists were excluded. Searches were conducted from five databases:

  • Cumulative Index to Nursing and Allied Health (CINAHL)
  • Medline Complete
  • Psych INFO
  • Applied Social Science Index and Abstracts (ASSIA)
  • Web of Science

Other sources included the Royal College of Nursing, Nursing Times and Nursing Standard.

Key search terms: Child Protection or Safeguarding Children and Supervision and Community nurses.

The search paper findings are set out and displayed utilising the 4 stages of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement – identification, screening, eligibility and included papers (Moher et al, 2009), see figure 1.


Findings and Discussion

Overall the papers in this review were not robust enough to draw any definite conclusions as they all had limitations which most acknowledged.

However, in general there were factors deemed both helpful and unhelpful in the supervision process. There were also relationship factors considered to be of importance (see table 2).

The overarching purpose of safeguarding supervision is to ensure quality and the health and well-being of those that we work with in our practice. The Care Quality Commission requires that service users are safeguarded (CQC, 2015).

Little et al (2018) carried out interviews with 25 community practitioners and safeguarding nurse specialists (see table 1). Their findings suggested that safeguarding supervision helped develop practice by improving practitioners’ reflective skills and helped with giving greater clarity. Similarly, Smikle (2017) supported this finding. However, Hackett (2013), Green-Lister and Crisp (2005) disagreed with this suggesting that more clarity was required, which was echoed by White in her findings carried out amongst her 11 School Health Practitioners (2008). Confusion was particularly evident within school nursing (Hackett, 2013). Hall’s (2007) paper brought out the perceived lack of clarity between clinical and safeguarding supervision in practitioners. There was also confusion around models of supervision highlighted by Wallbank and Wonnacott (2015). Hall (2007) raised the question about a national standard for child protection supervision back in 2007, but to date there is still no national standard. Instead each Trust adopts its own model without any evidence to suggest whether it helps to protect children better.  

Warren (2018) suggests that being held to account was thought to add to quality outcomes along with leadership skills deemed necessary for this to take place. A lack of leadership was first suggested by Laming (2003) within social workers. It raises the question as to whether good leadership equates to quality supervision. Rooke (2015) suggests that more support for practitioners leads to quality outcomes for children. Whereas Botham (2013) suggests that being an experienced practitioner is integral to effective safeguarding supervision.

Warren (2018) puts forward the idea that an effective supervisor is dependent upon whether the practitioner has knowledge and expertise in the field, and links this to training and leadership skills. Smikle (2017) in her study carried out with 11 safeguarding supervisors who received the 5-day training from the National Society for the Protection of Cruelty to Children (NSPCC) suggests training is of value and associates it with positive outcomes for children and families. This is supported by the RCN guidance (2014) stating ‘all practitioners delivering safeguarding supervision should have undergone the NSPCC child protection supervision course or equivalent’ (RCN, 2014). More evidence is needed as to whether safeguarding supervisors should receive specific training before becoming safeguarding supervision practitioners. Specialist training may assist in helping practitioners to safeguard children or they may simply learn by having gone through the lived experience, as suggested by Hackett (2013).

Wonnacott states that, ‘engaging in experience is not sufficient. Without reflecting on the experience, it may be lost or misunderstood’ (Wonnacott, 2016). This suggests that supervisors should be applying a reflective model in safeguarding supervision. To date there is no model of safeguarding supervision advocated for practitioners despite calls for such (Hall, 2007 and White, 2008). Little et al (2018) suggest a child-centred approach should be used as this allows the voice of the child to be heard.

Hackett (2013) and Hall (2007) say that there should be additional training as there is a need amongst frontline nurses. It is possible that perceived lack of training may be contributing to the anxiety of practitioners in dealing with child protection cases, especially when families of concern do not meet the threshold for take up by social care (Rooke, 2015). Rooke (2015) suggests that front-line practitioners are left holding onto high risk cases without the support of social care when they do not reach the threshold for take up. This is where safeguarding supervision is crucial in safeguarding children and in supporting practitioners to be safe and effective in order to reduce the stress and burnout associated with this type of work (Wallbank and Wonnacott, 2015). Davis and Cockayne (2005) suggest that practitioners value the informal emotional support that they get from their peers, as this provides the timely support that is required in-between more formal supervision of cases, which is affirmed by Rooke (2015).

Despite the words of Laming in 2009 that ‘regular, high quality supervision is critical’, there is currently no national guidance on how regular safeguarding supervision should be carried out; this decision again is primarily down to the individual organisation and policy makers. Jarrett and Barlow (2014) suggest that regular supervision bi-weekly is more beneficial to practitioners. Although peer support can help with addressing the emotional needs of front-line practitioners, it is questionable whether peers would challenge one another on their practice, and it is this that is required to protect children. Practitioners also want to be challenged (Hall, 2007) but need to be supported to do this (Rooke, 2015). It has been well documented in high-profile Serious Case Reviews and subsequent inquiries held following the death of Victoria Climbié and Peter Connelly (Laming, 2003 and 2009), that governance was not adhered to and practitioners were not being challenged and this led to devastating consequences for children.

Table 1 – Data Extraction Table

Article

Participants

Aim

Method of Data Collection

Method of Data Analysis 

Overview of Findings

Botham, J 2013 (UK, Australia and USA)

N/A

To critically examine the available literature on what constitutes safeguarding supervision for health visitors and school nurses

Literature review

Themes

Clear need for safeguarding children supervision. Health visitors and school nurses have a crucial role in this. Supervision models, and mode are open to interpretation. A model and framework would improve quality and provide effective evaluation of the supervision process.

Green-Lister, P and Crisp, B.R 2005 (UK)

99 Nurses and Nursing Managers

To explore community nurses’ and nursing managers’ understanding of (a) their professional responsibilities in relation to child protection, (b) the training needs of community nurses in respect of child protection, (c) their support and supervision needs.

Semi-structured interview

Thematic Analysis

Lack of clarity across the trust on model, regularity, nature and purpose of clinical supervision.  Management culture that hinders the process.

Hackett, A. 2013 (UK)

6 School Nurses

To explore the perceptions of school nurses in child protection

Identify skills required to undertake this role.

Identify training needs.

Semi –structured interviews

Thematic Analysis

Confusion in role when it came to child protection. Need for training in order to meet needs. Lack of time and workload barriers prevented child protection training to occur.

Hall, C. 2007 (UK)

11 (total)

6 Health Visitors and 5 School Nurses

To appreciate how health visitors and school nurses perceive child protection supervision.

Focus Group

Thematic Analysis

Child protection supervision was of value to practitioners although time consuming. They identified a need to be supported and the opportunity to discuss families of concern.

Jarrett, P. and Barlow, J, 2014 (UK)

15 Home Visitors (family nurses)

To explore the perceptions of health visitors working in frontline child protection using the family partnership model.

Interviews

Thematic Analysis

Health visitors now working as family nurses with high risk families perceived regular supervision to have had a significant impact on their practice. The model of clinical supervision used, the organisational culture in which supervision was provided, and the professional background of those who delivered the clinical supervision were all perceived to be important factors in determining success.

Little, M: Baker, T and Jinks, A.M 2018 (UK)

25 Community Practitioners and Safeguarding Nurse Specialists (11 interviewed and 14 completed survey)

To investigate the effectiveness of safeguarding supervision offered by a community nursing service and to identify factors that may facilitate or hinder its delivery

Interviews -open ended questions/

online survey

Thematic content analysis

Safeguarding supervision was viewed as child focused, helpful activity that has led to practice improvements. It can be intrusive, punitive and time consuming. Children discussed should include those that are of concern but not on a child protection plan.

Rooke, J. 2015 (UK)

10 Health Visitors

To examine the experiences of health visitors who work in child protection and safeguarding.

To discover what health visitors, view as supportive in their role.

To understand the impact of support on health visitors.

 

Focus Group

Thematic Analysis

Health visitors gain most of the support from their colleagues and from safeguarding supervision processes. They felt supported in their role in managing their emotions, feeling safe and effective in practice having time to reflect and evaluate.

Smikle, M. 2017 (UK)

12 Safeguarding Supervisors

Training of supervisors to provide safeguarding supervision.

Narrative feedback following training

Thematic Analysis

Safeguarding and child protection specific skills training enabled supervisors to apply theory to practice in supporting practitioners.

Wallbank, S and Wonnacott, J. 2015 (UK)

Not clearly stated

To review a new model of supervision – the integrated restorative model.

N/A

N/A

Not clear but calls for more explicit guidance relating to the type of model used within safeguarding supervision, which would be welcomed by professionals.

Warren, L.  2018

(UK)

N/A

Not clearly stated

Literature review

N/A

Not clear but suggests that findings are comparable to NSPCC framework as well as Laming’s and Munro’s recommendations on better leadership in protecting children.

White, J. 2008 (UK)

11 School Health Practitioners

Steering group set up to review safeguarding supervision.

Action learning sets/Group interview

Evaluation Tool – 14 statements

New model of supervision introduced which includes both 1:1 and group working well within Westminster Trust.

 

Thematic Synthesis Table 2

Themes:

Sub-themes:

 

Factors that contribute to Effective Supervision

Experienced Practitioner/Ability to Lead

(Helpful)

 Governance

 

  Challenged on practice

 

  Critical reflection

 

Training

 

Regularity  

 

Model/Mode

Challenges to Effective Supervision

   Lack of resources – Time/Staff

(Unhelpful)

   Confusion in terminology, role, and models

 

   Lack of Training/CPD  

 

   Organisational Culture

The Supervisory Relationship

    Support/Containment

 

   Openness/Honesty/Trust

 

   Feeling Safe/Safe Environment

 

 


Conclusions

It must be noted the methodological limitations of the papers reviewed, in that all but one paper by Green-Lister and Crisp (2005) had a limited number of participants. There were only two papers that had outsider researchers, Green-Lister and Crisp (2005) and Jarrett and Barlow (2014), so insider bias must be considered. However, all papers do make suggestions there may be some factors that contributes to effective supervision and how the supervision process helps in reducing anxiety, stress and burnout (Hall, 2007, Rooke 2015 and Wallbank and Wonnacott, 2015). Health visitors, school and family nurses recognised some factors that supported them in the supervision process such as challenge, reflection and emotional support. These were amongst the factors mentioned in Smikle’s (2017) definition of safeguarding supervision. Family nurses valued receiving supervision from a supervisor of a different professional background and having it on a more regular fortnightly basis (Jarrett and Barlow, 2014). The relationship between the supervisee and the supervisor was important, and the provision of a safe place to reflect on practice issues was crucial to positive outcomes for children and families (Wallbank and Wonnacott, 2015).

Practitioners were also able to identify the barriers which prevented them from accessing this in practice; lack of resources, time and staffing issues. This was more of an issue amongst school nurses (Hackett, 2013). Lack of training was also more of an issue in this group of professionals as there was a perceived lack of confidence in this area of nursing. Little et al (2018) highlighted other unhelpful aspects of supervision; it was perceived as being punitive and a ‘tick box exercise’.

All papers reviewed focused on the perception of nurses about what they felt was helpful or hindering with regards to safeguarding supervision. It is unknown whether safeguarding supervision helps to decrease risks and increase protection by delivering positive outcomes for children; more evidence is needed to support this.


Implications for practice

  • Safeguarding supervision needs to be viewed as a standalone form of supervision to avoid any confusion in terminology with clinical supervision. 
  • Safeguarding supervision should be child-focused and be able to assess risk through challenge and critical reflection.
  • Safeguarding supervision should include children of concern, not just those on a child protection plan.
  • Safeguarding supervision must enable the practitioner to feel safe and offer the support needed to ensure quality outcomes for the child.

Recommendations for further research

  • More research is needed into the application of model, mode and regularity of supervision to see if any of these factors provide better outcomes for children and families.
  • Safeguarding supervisors may benefit from having specific safeguarding supervision skills training prior to taking up their role.
  • Leadership skills training may have an impact on providing better outcomes in protecting children from harm. 

References

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Botham, J. (2013) What constitutes safeguarding children supervision for health visitors and school nurses. Community Practitioner, 86(3): 28-34. See https://www.ncbi.nlm.nih.gov/pubmed/23540016 (accessed 15 October 2019).

Care Quality Commission. (2013) Supporting Information and Guidance. Supporting Effective Clinical Supervision. See: https://cqc.org.uk/sites/default/files/documents/20130625_800734_v1_00_supporting_information-effective_clinical_supervision_for_publication.pdf  (accessed 15 October 2019).

Care Quality Commission (2015) Statement on CQC’s roles and responsibilities for safeguarding children and adults. See: https://www.cqc.org.uk/sites/default/files/20150710_CQC_New_Safeguarding_Statement.pdf  (accessed 15 October 2019).

Cutcliffe J, Butterworth T, Proctor B. (2001) Fundamental Themes in Clinical Supervision. Routledge, London.

Davis G, Cockayne D. (2005) Peer support in child protection practice. Journal of Community Nursing, 19(10):18-21.

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Hall C. (2007) Health Visitors' and School Nurses' Perspectives on Child Protection Supervision. Community Practitioner 80(10): 26-31. See https://www.researchgate.net/publication/233524926_Health_visitors'_and_school_nurses'_perspectives_on_child_protection_supervision (accessed 15 October 2019).

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Laming L. (2009) The Protection of Children in England: A Progress Report - Lord Laming Report. The Stationery Office: London. See https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/328117/The_Protection_of_Children_in_England.pdf (accessed 15 October 2019).

Little M, Baker T, Jinks AM. (2018) A Qualitative Evaluation of Community Nurses’ Experiences of Child Supervision. Child Abuse Review 27(2):150-157. See https://onlinelibrary.wiley.com/doi/abs/10.1002/car.2493 (accessed 15 October 2019).

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Munro E. (2011) The Munro review of child protection: final report, a child-centred system.  The Stationery Office: London. See  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/175391/Munro-Review.pdf (accessed 15 October 2019).

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Smikle M. (2017) Preparing supervisors to provide safeguarding supervision for healthcare staff. Nursing Management 24(8): 34-37. See https://www.ncbi.nlm.nih.gov/pubmed/29185294 (accessed 15 October 2019).

Wallbank S, Wonnacott J. (2015) The integrated model of restorative supervision for use within safeguarding. Community Practitioner 88(5): 41-45. See https://www.researchgate.net/publication/281780985_The_integrated_model_of_restorative_supervision_for_use_within_safeguarding (accessed 15 October 2019).

Warren L. (2018) Role of leadership behaviours in safeguarding supervision: a literature review. Primary Health Care 28(1): 31-36. See https://journals.rcni.com/primary-health-care/role-of-leadership-behaviours-in-safeguarding-supervision-a-literature-review-phc.2018.e1340 (accessed 15 October 2019).

White, J. (2008) A model of child protection supervision for school health practitioners. Community Practitioner 81(5): 23-7. See https://www.ncbi.nlm.nih.gov/pubmed/18549119 (accessed October 15 2019).

Wonnacott J. (2016) Developing and Supporting Effective Supervision. Pavillion: Hove.

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