- ĐĄĐ”Ń ŃŃŃÎłŐĄĐČŃ áœÎčŃáŠĐ»á
- ĐĐ° Đ°Đ¶ĐŸÎŒ
- ŐĐ°ĐżŃÎ±ŐŹŃ Đč Đ”ĐČ áąĐż
- áŸŐžÖáĄáąÖογ Ő„á áŐ«ÖĐŸá°
- Őá°ĐœĐŸÏ ŃÖĐ°ÎČէչДŃ
lululemonmakes technical athletic clothes for yoga, running, working out, and most other sweaty pursuits. As always, shipping is free.
Medical education and training Enablers and barriers to effective clinical supervision in the workplace a rapid evidence review Rothwell1, Kehoe2, Sophia Farhene Farook3, Illing41School of Medical Education, Newcastle University, Newcastle upon Tyne, UK2Health Professions Education Unit, Hull York Medical School, York, UK3Emergency Medicine, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK4Health Professions Education Centre, Royal College of Surgeons in Ireland, Dublin, IrelandCorrespondence to Dr Charlotte Rothwell; AbstractObjectives We aimed to review the international literature to understand the enablers of and barriers to effective clinical supervision in the workplace and identify the benefits of effective clinical A rapid evidence sources Five databases CINAHL, OVID Embase, OVID Medline, OVID PsycInfo and ProQuest were searched to ensure inclusion and breadth of healthcare criteria Studies identifying enablers and barriers to effective clinical supervision across healthcare professionals in a Western context between 1 January 2009 and 12 March extraction and synthesis An extraction framework with a detailed inclusion/exclusion criteria to ensure rigour was used to extract data. Data were analysed using a thematic qualitative synthesis. These themes were used to answer the research The search identified 15 922 papers, reduced to 809 papers following the removal of duplicates and papers outside the inclusion criteria, with 135 papers being included in the full review. Enablers identified included regular supervision, occurs within protected time, in a private space and delivered flexibly. Additional enablers included supervisees being offered a choice of supervisor; supervision based on mutual trust and a positive relationship; a cultural understanding between supervisor and supervisee; a shared understanding of the purpose of supervision, based on individual needs, focused on enhancing knowledge and skills; training and feedback being provided for supervisors; and use of a mixed supervisor model, delivered by several supervisors, or by those trained to manage the overlapping and potentially conflicting needs of the individual and the service. Barriers included a lack of time, space and trust. A lack of shared understanding to the purpose of the supervision, and a lack of ongoing support and engagement from leadership and organisations were also found to be barriers to effective clinical This review identified several enablers of and barriers to effective clinical supervision and the subsequent benefits of effective clinical supervision in a healthcare & training see medical education & traininghealth services administration & managementorganisational developmentorganisation of health servicesquality in healthcareData availability statementData sharing not applicable as no datasets generated and/or analysed for this is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial CC BY-NC license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See Statistics from Request Permissions If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Centerâs RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways. education & training see medical education & traininghealth services administration & managementorganisational developmentorganisation of health servicesquality in healthcareStrengths and limitations of this studyThis paper was based on evidence identified in the international literature using a rapid review, which involves a systematic search and rigorous were limited to Western only and the last 10 years for pragmatic in many areas there was a vast amount of information, which provides strength to the findings, a rapid review necessarily pays less attention to study design and sample of the data were heterogeneous in nature, and this also hindered our ability to relate the findings to specific professions and findings drawn from the overall themes were evident across much of the what makes clinical supervision effective and learning more about the barriers to and challenges of effective supervision are important concerns for the health and social care workforce. Most organisations provide some provision, but many lack an understanding about why it is important, who should be involved, what the possible benefits are and how it could be is at the core of practice for all health and social care professionals, where there should be a sense of shared responsibility for the effectiveness and safety of It is important to understand this complex process to ensure best practice for all participants involved practitioner, service delivery manager, clinical supervisor, peers, clients and other service users, the profession itself.Supervision has been described as an event that involves an ongoing professional relationship, between two and more staff members with different levels of knowledge or expertise, to support professional development and to enhance knowledge and Definitions of supervision emphasise the promotion of professional development in addition to ensuring patient safety. For example, Nancarrow et al2 focus on the progression of clinical practice through professional guidance and support and refer to Proctorâs3 three functions of supervisionâmanagerial/administrative, educational and supportive. All three functions should be overlapping and has been suggested that there are many forms of supervision internal managerial, internal reflective, external professional and external 4 At one end of this continuum, managerial supervision takes place inside the organisation and is mostly focused on task and process. At the other end, personal supervision is worker focused and centres mainly on the narrative brought into the supervision space by the This last type of supervision personal has been highly valued by workers to air their feelings; providing a safe place to connect and self-reflect. Personal supervision allowed a more intensive focus on clinical issues and personal professional development rather than organisational Two types of supervision tend to coexist when the line manager is also the clinical supervisorâa focus on practitioner learning and development, and another focused on service delivery, risk management and underperformance. Kilminster and Jolly5 argued for clarity on dealing with underperformance in addition to identifying what helps and hinders effective clinical supervision. Managing this split highlights the need for supervisor this review, we used the following definition of supervision as it encompassed both personal development and service development in the context of a relationship extending over timeThis relationship is evaluative, extends over time and has the simultaneous purposes of enhancing the professional functioning of the more junior person and monitoring the quality of the professional services. Bernard and Goodyear, p86While it is evident that supervision is important, we must now understand exactly what aspects of supervision we should be focusing on, and it is hoped that best practice can be sought from looking across such a range of different healthcare professionals. Any critical differences that impacted on supervision across health professions were also the focus of supervisionThe aim of this rapid review was 1 to syntheses the evidence of international literature on the enablers of, and barriers to effective clinical supervision in the workplace; 2 to identify the benefits of effective clinical supervision in the Rapid Evidence Assessment REA was used in this study. A REA is similar to a systematic review in that they both use rigorous methods of appraising and synthesising evidence from published However, restrictions on the data retrieved are placed on the search at the data collection strategyThe research protocol was developed with advice from a data analyst at Newcastle University. As a result, we refined our initial search strategy and targeted the most appropriate databases. The following databases were used to ensure a breadth of health and social care professions were included CINAHL, Allied and Health Professionals literature, OVID Embase, OVID Medline Medical literature, OVID PsycInfo, Psychological literature and ProQuest Social Science literature. See the Search strategy section for a breakdown of search terms systematic search see online supplemental material 1 for search strategy of each database was carried out in line with our search strategy. As is typical of rapid reviews, limits were placed on the search to ensure the research could be done in a timely manner. For example, only including papers from the last 10 years ensured we were able to capture the most relevant documents for current supervision practice in a shorter space of time. Search terms were developed to include a comprehensive list of healthcare professionals, supervision types and forms of effectiveness. Restrictions were placed on the databases in line with our search materialProcedure for screening of data, data extraction and ensuring quality assuranceAll citations were downloaded to EndNote reference management database and duplication was removed n=2683. Authors independently reviewed the same 500 titles and abstracts to make sure that the same papers were being included/excluded. Any discrepancies were discussed and the inclusion/exclusion criteria were refined as needed see box 1. All 13 239 titles and abstracts were screened by two researchers CR and AK.Box 1Revised inclusion/exclusion criteriaInclusion criteria for papersPapers that include clinical supervision and/or peer support in the that include a regulated healthcare published within the last 10 years 1 January 2009â12 March 2019.Papers that include primary research and systematic which are quantitative, qualitative or mixed written in reporting on a Western culture criteria for papersFocus not on formal and structured clinical/peer supervision by this we mean that the supervision was not a one offâ event but must have some ongoing relationship, as detailed in the very definition of supervision.Not in healthcare evidence based eg, opinion pieces, letters or weak evidence.Paper not written in English/outside review of children/animals/ culture pilot data extraction exercise was conducted to ensure quality assurance. This exercise involved all four reviewers independently reading full papers and was repeated with a further 10 papers to check consistency of inclusion/exclusion and data extraction. The data extraction framework was revised following this initial review of papers. The clear inclusion/exclusion criteria and detailed data extraction form were used to ensure rigour. The data extraction form has been added as online supplemental material 2. Regular meetings were held between all four reviewers to ensure quality was maintained and to discuss uncertainties or queries that arose from the papers, and it was during this phase that the definition of clinical supervision was identified .Supplemental materialSynthesis of papersOnce the data were entered onto the data extraction database see online supplemental material 2 for the data extraction form, the data were analysed using a qualitative thematic synthesis,8 which is a useful approach when aiming to pull out common elements across the heterogeneous literature. These themes were used to answer the research and public involvementPatients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our full review of papers was conducted on 809 publications from nearly 16 000 initially identified see figure 1. The final number of included papers was 135, with 674 being demographicsSettingA range of countries were represented within the included papers, with the majority being from Australia 38, the UK 31, the USA 24, New Zealand 11 and Canada 7. The findings were further diversified by the broad set of health and social care professions included in the review. The majority of papers included doctors, nurses, psychologists and social workers. Examples of other allied health professionals included were music therapists, physiotherapists, occupational therapists, speech and language therapists, podiatrists and designsPapers included in the review were a mix of qualitative papers 53 using interview or focus group data and quantitative papers 50 using surveys and questionnaires. Several papers used a mixed-methods approach 15 and literature reviews 15, case study 1, action research 1, unidentified 1.Type of supervisionOf the included papers, a large majority focused on clinical supervision 110, with a minority focusing on peer supervision 22 or both 3. These included both individual and group supervision sessions. Within the literature, there were several types of clinical supervision and peer supervision discussed. However, there was not always a clear distinction between different types of supervision, and terms were often used interchangeably such as peer supervision and peer mentoring. The working definition we used was clinical supervision, which was conducted either in a one-to-one or small group situation by a senior staff member or by a more experienced staff member at the same level. Clinical supervision included action planning; reflection on clinical situations; role development and training; indirect and direct supervision; and included supervision from both internal and external research questions were answered using evidence from this literature are the enablers to effective clinical supervision?An open, supportive and safe environmentThere was considerable evidence to highlight that having an open and safe environment where supervisees feel comfortable and trust their supervisor is an integral part of 9â34 Having the time to discuss personal issues based on the needs of the individual was identified as an important focus for 32 35â37 There was also evidence of the value of time spent reflecting on practice, including ethical issues14 15 18 28 38 39 and of receiving 30 32 39â42Establishing a supervisory relationship based on trustBeing able to develop a positive relationship with a supervisor that was based on trust was seen as key by a wide range of 4 10 11 28 39 42â46 Supervisors who were deemed experts in their own profession were also more likely to be viewed as credible and trustworthy, and supervisees felt they were better placed to support 12 32 46â48 Trust was also underpinned by having the opportunity to be able to explore each otherâs belief and value systems in a neutral space, away from organisational hierarchies and the workplace and where emotions could be managed in an open and reflective way10 49 and when the supervisee respected the supervisor personally and professionally and both parties could self-disclose 50Regular supervision with timely feedbackMany studies reported on the importance of receiving regular and constructive feedback during supervision2 14 15 32 40 44 51â54 and having the time to reflect on 15 18 28 42 51 55 Supervision was valued for the sharing of tacit knowledge, for providing real-time feedback41 and when it provided confirmation that staff had done the right majority of the literature reviewed did not specify supervision frequency. There was scant evidence on how often clinical supervision should take However, Dilworth et al57 reported that supervision should take place on a monthly basis to ensure sufficient support. Furthermore, McMahon and Errity27 reported that supervision that was less than fortnightly was insufficient and healthcare workers who spent at least 60 min in supervision perceived their supervision to be more relationships develop over time and are complex,59 therefore supervision should not be a one-off activity, instead, it needs to be sustained over time and from early on in a However, the importance of providing unplanned discussion time to support emerging needs and ensure staff well-being was also for supervisorsSupervisors need to have training in cultural awareness to enable them to be culturally competent. This was seen as an asset leading to improvements in communication, reflection and 10 62 Supervisors also need to be trained on listening skills30 32 63 and helping supervisees to problem Findings showed that it was important that the supervisor was able to not only provide feedback, but also receive it 15 30 32 41 42What are the benefits of effective clinical supervision?Job satisfaction and staff retentionSeveral studies reported that effective supervision was found to have a positive impact on staff retention,61 65â67 job satisfaction,13 68 69 staff well-being63 70â72 and perceptions of being Wilson et al32 found that feedback from supervisors facilitated learning and encouraged staff development. Continual Professional Development CPD and training for supervisors themselves were also found to increase Regular supervision was found to increase staff McMahon and Errity27 reported that greater supervision frequency, with regular progress reviews, was significantly related to positive stress and anxietySeveral studies found that supervision reduced stress and 22 44 47 70â72 75â78 Evidence suggested that the reduction in stress and anxiety came about as supervision provided a medium for sharing skills, knowledge and resources, in a supportive 44 47 A reduction in stress for supervisors was also found, following the provision of training and CPD support for Studies reported that supervision helped participants to manage their feelings,44 76 also improving understanding of the importance of well-being and learning to help reflect on working environmentResearch highlighted that effective supervision and a supportive working environment can improve the uptake of workplace policies as supervisees understand the importance and reason for the Better teamwork, relationships and more support in the workplace can also help with professional A study by Davis and Burke16 reported that supervision with nurse managers improved communication among staff and facilitated reflection, sharing ideas and quality of care deliverySeveral studies made links with the provision of effective supervision and an increase in quality of 23 71 72 76 80â82 A study carried out by da Silva Pinheiro and de Carvalho76 reported group supervision with nurses had helped them to manage their feelings, which they linked to an increase in quality of care for their patients. Claridge et al81 looked at whether direct supervision with resident doctors increased patient outcomes. Results showed that with direct supervision, there was a greater uptake of compliance with managerial protocols, and as a result patient outcomes were are the barriers to effective clinical supervision?Lack of time and heavy workloadsOne of the main barriers identified for effective supervision was a lack of time and heavy 17 21 25 35 41 48 57 73 83â98 Many studies reported that supervisors were unable to find time for supervision due to busy work environments, which ultimately restricted supervisor flexibility and quality when they did find the 82 99 Other studies reported a lack of opportunity and time for reflection within supervision, which left staff feeling that they had to figure things outâ for themselves without adequate 84Many noted that supervision was not a priority, for both supervisor and 27 60 71 72 94 100 As a result, supervision was sometimes perceived to be a bonus,11 feeling that they were expected to not dwellâ on stressful workplace issues. There was often an expectation that supervisors had the time to develop relationships and would take the time to complete the necessary paperwork prior to and following supervision, which could be lack of adequate resources could lead to an overstretched workforce not being able to support each other effectively, and a decline in clinical supervision due to pressures on staff Kenny and Allenby60 discussed a lack of monetary incentives for supervision, affecting how supervision was perceived and whether it was provided or attended. Supervisees only wanted to attend supervision when it was within work time and when there was protected time for of staffing, shift workingThe type of clinical environment could facilitate or hinder clinical Key factors were organisation location, shift work patterns and work-environmental factors quantitative demands, tempo, cognitive demands, influence at work and social support. Jelinek et al51 discussed that there was a reduction in supervision levels during unsociable shift patterns. Supervision was dependent on service demands and was often not seen as a priority if there was insufficient staff numbers in busy environments. Differences seemed to not only reflect culture regardless of policy asserting its importance but also ease of access to supervision. For example, there was a lack of supervision outside day shifts or in rural communities with fewer staff despite the potential for increased need due to professional 33 60 101Lack of management/organisational supportOrganisational culture and attitude toward supervisory practice were found to be important, needing managerial support and 101 If management do not recognise the importance of supervision, it is unlikely it will become embedded into the organisational culture, and a lack of commitment from organisations and managers can act as a barrier to providing the time and resources required for effective 27 31 37 73 93 101 102 In busy agency settings, supervision can often be neglected or deferred, to accommodate the latest crisis, unless it is made a priority by A study exploring which nurses decided to participate in clinical supervision found that support from empowering and fair leadership was crucial, affecting the adoption and uptake of clinical supervision, both positively and of supervisor training and supportSeveral studies reported that a lack of training for supervisors was a barrier and resulted in ineffective 38 64 76 91 92 104â107 Supervision was varied and individual when no direction about how to approach it was Studies also reported a lack of quality in supervision when supervisors were unfamiliar with professional guidelines ie, standards set by regulators, their role and responsibilities as a supervisor, ethical standards set in place by employers and inadequate educational of supervisor competence and skills was identified in a number of studies highlighting barriers to effective clinical supervision, such as being intolerant, blameful and inflexible,2 being unable to deal with unmotivated supervisees76 87 and manage differing personality types,108 the lack of ability to share feelings,49 inability to give appropriate feedback51 and an inability to understand personal of understanding and support when dealing with underperformanceSupervision should facilitate learning opportunities when However, supervisors do not always have the time and opportunity to upskill staff or work with those who are Kilbertus et al111 also found that some supervisors reported not feeling able or comfortable in recognising and managing a failing trainee. Issues arose when either the supervisor or supervisees were unaware of the superviseeâs lack of knowledge and 33 47A lack of support from employers was noted by supervisors when raising concerns about staff,51 not always being told where to signpost supervisees to if there were any concerns or needs outside of their remit eg, mental health support. Supervisors themselves may also need to seek Supervisors also feared that if they gave supervisees negative feedback, that in turn they would receive negative teaching evaluations, and this would impact on their own future promotion and There was also evidence that clinical supervision was delegated to the most junior consultants, with the least experience to deal with complex underperforming Kilbertus et al111 highlighted that a lack of continuity of feedback meant that it was easy for struggling residents to fall through the with supervision from another discipline or from an external organisationExternal supervisors who work in a different organisation to their supervisee and interprofessional supervision supervisors from a different profession may require additional training and 4 60 Interprofessional supervision can sometimes lead to misunderstanding due to differences in roles, responsibilities and levels of training. There may also be an absence of shared theory, language, differences in professional decision-making processes and codes of In addition, an oversight of ethical practice could be weaker with an interprofessional It may also disadvantage supervisors with regard to the professional role, not being able to raise all issues, and causes disempowerment due to differences in professional status1 and places a burden of responsibility on the supervisor to have a good working knowledge of the context of practice of other states that an external supervisor will hold less information about the practitioner compared with an internal supervisor, who will likely identify managerial concerns more effectively. Having an external supervisor, however, increased the likelihood that supervision took 114 115 Yet it was the supervisee who mainly set the agenda with regard to issues to be discussed, and therefore underperformance was more likely to remain concealed. This type of supervision highlights the weakness of self-assessment, which is a particular concern for those who are of relationship and trustSupervisees need to feel that they can trust their supervisor,52 yet sadly, this was sometimes 17 61 84 117 118 Unhelpful and untrusting relationships led participants to distrust their supervisorâs advice, or be selfâ 52 Palmer-Olsen et al44 found that supervisors who did not establish a secure supervisory alliance were less effective in helping their supervisees learn to implement a specific therapy. A lack of supervisor commitment, or when supervision was reduced to a tick boxâ exercise, or too bureaucratic, it was found to be less 61 85 It was also noted that sometimes people did not fitâ with their 39Lack of understanding about what supervision was and its purposeSeveral studies reported a lack of a common understanding about the role and purpose of 60 97 100 119 On such occasions, supervisees reported anxiety and sometimes perceived that supervision equated to 32 44 60 73 120 Negative associations with the term clinical supervisionâ also led to a lack of 37DiscussionThis rapid systematic review aimed to identify the enablers of and barriers to effective clinical supervision and identified the benefits of supervision for supervisees and supervisors within the in place and done well, clinical supervision has many benefits for the organisation, professional development and patient services, and each of these three levels makes an important contribution to ensure benefit is achieved. This review has highlighted evidence which indicates what needs to be in place to ensure clinical supervision is effective. Evidence from the literature review indicates that the organisation plays a key role in ensuring supervision takes place,60 95 102 that it is valued and expected,73 95 that supervisors are trained29 37 68 79 91 99 104 121 and time is 25 79 92 99 122 Supervision needs to be provided in a neutral, open, supportive environment to facilitate discussion and reflection on clinical practice, career development and any personal issues that may arise in the 9 10 13â16 18 20 21 23â26 29 30 32â34 44 117 123â125Having a relationship based on trust with the supervisor was also found to be 4 10 11 28 32 39 42â46 There was also evidence on the benefit of reflecting on practice18 28 and on receiving 40 41 Having regular but flexible supervision that fitted around all stakeholdersâ needs was also highlighted as important. Clinical supervision provides the chance to facilitate learning opportunities when needed98 and to upskill staff who were was much evidence about the positive benefits of clinical supervision, in that those who received support through clinical supervision were better able to cope with the demands of the job23 75 and were less likely to 126 Effective supervision increased resilience78 and job 69 127 There was also evidence to suggest that supervision helped with reducing stress and Supervision was also seen to drive up the quality of care and has a positive effect on the working 23 71 77 80â82 87A number of barriers were highlighted within the literature that should be taken into consideration when exploring how to implement effective supervision practice. These included a lack of time and heavy workload,2 16 17 21 35 41 48 54 57 64 73 83â85 87â96 98 a lack of resources,18 37 60 unsupportive management and colleagues,2 27 31 73 93 102 128 a lack of supervisor training,11 17 32 38 64 76 91 92 105â107 124 and a lack of trusting relationships and ongoing 17 45 61 75 84 117 118 Supervisees were also sometimes unaware of the purpose of the supervision practice,2 60 64 100 119 impacting on A recent study has highlighted the need for supervision to include patient care, concluding that the usual model of meeting for a supervisory discussion away from patient care was not found to be Although this is an interesting and important finding, our findings would suggest that the overall supervisory experience is not as simplistic as this. There is a need to take into account all of the factors and levels presented in this paper, there being no single answer leading to effective were no critical differences identified across the range of healthcare professionals in terms of ensuring effective supervision is in place, with similar themes being apparent across all. Naturally, professions such as psychologists and social workers will face different challenges and have different needs from their supervisory relationship; however, this is part of the supervisory process and identification of those needs is what will make it an effective experience for the is clear from the evidence that support from management is needed to enable effective implementation, including cost and training for staff. However, this review has highlighted that supervision is subject to different interpretations by managers, who tend to focus more on service delivery rather than on staff development, and agreeing on the shared purpose of supervision is important to reduce 10 Beddoe1 argued that managerial supervision creates a shift from being practitioner focused to a monitoring agenda. Problems seem to arise when the focus was perceived to be monitoring performance, rather than on the provision of 9 10 39 42 115 Pack72 highlights that line managers need to focus on protecting the employing organisation and their patients/clients from risk,96 whereas external supervisors can focus more on the personal development. This split may offer a solution that avoids the inevitable tension experienced by a manager who is also the clinical supervisor. The issue of managing underperformance alongside personal development further highlights this tension and indicates again that having two different supervisors might offer a solution; like experienced by junior doctors in the UK, who have an educational supervisor who overseas educational development and a clinical supervisor who overseas clinical practice. A split role, when feasible, might be the preferred solution and when this is not an option then supervisors need training to support them to manage these challenges. The model of practice which is best is a source of continued debate. However, what is clear is that there is no one size fits allâ for clinical supervision and all stakeholders need to consider how to make their supervision as effective as it can be and involve discussion to agree on the shared purpose of clinical paper was based on evidence identified in the international literature using a rapid review, which involves a systematic search and rigorous analysis. Although in many places there was a vast amount of information, which provides strength to the findings, a rapid review necessarily pays less attention to study design and sample sizes. An additional limitation of this rapid review was that the study focused on publications in English, studies set in Western only settings and publications within the past 10 years only. Much of the data were heterogeneous in nature, and this also hindered our ability to relate the findings to specific professions and settings. However, the findings drawn from the overall themes were evident across much of the review has identified the following enablers of and barriers to effective clinical supervision with regard to the organisation, the supervisor and included having a set place and a regular time slot for supervision to ensure it takes place. It is more likely to occur when a private space is made available and when protected time is available. Also, there needs to be some flexibility to enable staff working irregular hours such as night shift to access clinical supervision. Barriers to supervision happening were apparent when these issues of place and time were not in key enabler identified was when the supervisory relationship was based on a positive relationship and on mutual trust. Ideally, supervisees should be offered a choice of supervisor and there should be some cultural understanding between them. When this is not the case, when the relationship lacks trust, this becomes a barrier, as does having to accept a supervisor not well matched to the supervisee and when cultural understanding is clinical supervision to be effective, there needs to be a shared understanding of its purpose. Ideally, this is based on the individual needs of the supervisee and the focus is on enhancing knowledge and skills to support professional development and improve the service. Barriers occur when there is no agreed purpose and no agreement or conflicting views on the focus of clinical review identified that a range of types of supervision can be effective one-to-one, group, internal, external and distance supervision can all offer a range of benefits. Going forward, having different types of supervision, with different people who offer different perspectives, should be considered and may overcome some of the barriers in place when only one, poorly matched, supervisor is available. Clearly, having different supervisors also overcomes the problem of having a line manager who is both the clinical supervisor and service manager and who may need to manage the needs of the service with the potentially conflicting needs to the individual. Lastly, providing training to supervisors is helpful to ensure they are supported and developed in this role and indeed also benefit from feedback themselves, without such training barriers to effective supervision may availability statementData sharing not applicable as no datasets generated and/or analysed for this statementsPatient consent for publicationNot Supplementary materials Supplementary Data This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the authors and has not been edited for content. Data supplement 1 Data supplement 2 Read the full text or download the PDF Log in using your username and password
Enoch85:4 After that I perceived other large and black cows; and behold all of them changed their stalls and pastures, while their young began to lament one with another. Again I looked in my vision, and surveyed heaven; when behold I saw many stars which descended, and projected themselves from heaven to where the first star was,
BattingRKBATTERDATEOPPSCOREABRH2B3BHRRBISBESPN*1Trevor Story, BOS5/19 SEAW Pederson, SF5/24 NYMW Rizzo, NYY4/26 BALW Perez, PIT6/30 MILW Guerrero Jr., TOR4/13 NYYW Tellez, MIL5/4 CINW Adames, MIL4/26 PITW Reynolds, PIT6/29 WSHW Carpenter, NYY6/12 CHCW Escobar, NYM6/6 SDW Hoskins, PHI6/14 MIAL Rodgers, COL6/1 MIAW Goldschmidt, STL6/14 PITW Farmer, CIN5/26 CHCW Naylor, CLE5/9 CHWW Paredes, TB6/21 NYYW Ohtani, LAA6/21 KCL Thomas, WSH6/3 CINW Jansen, TOR7/22 BOSW Suwinski, PIT6/19 SFW Mahle, CIN6/14 ARIW Buehler, LAD4/25 ARIW Kershaw, LAD4/13 MINW Ohtani, LAA6/22 KCW Gausman, TOR8/2 TBW Javier, HOU6/25 NYYW Alcantara, MIA7/5 LAAW Detmers, LAA5/10 TBW Rodon, SF7/9 SDW Pivetta, BOS5/18 HOUW Kershaw, LAD7/15 LAAW Wacha, BOS6/6 LAAW Cease, CHW5/2 LAAW Kuhl, COL6/27 LADW Mikolas, STL6/14 PITW McKenzie, CLE8/7 HOUW Javier, HOU7/1 LAAW Wainwright, STL8/13 MILL Verlander, HOU4/16 SEAW Morton, ATL7/3 CINL Glossary ESPN* 59 + H + R + .25*BB + .25*HitByPitch + TB + .25*SB - .25*CaughtStealing + .25*SacFlies + .25*SacHits + RBI - .25*K - .25*Outs GSC 50 + 1*Outs + 2*IP after the 4th + 1*K - 2*H - 4*ER - 2*UnearnedRuns - 1*BB SPORTS NFL MLB NBA NHL College Football College Basketball Soccer NASCAR MORE Racing Golf Tennis Boxing MMA Recruiting Olympic Sports Horse Racing FANTASY Football Baseball Streak for the Cash SPORTSNATION Polls VIDEO Most Recent MORE Music Arcade TOOLS Contact Us Corrections Daily Line RSS WatchESPN RADIO ESPN THE MAGAZINE SHOP SPORTSCENTER TEAM ESPN ESPN FRONT ROW NFLNBAMLBSoccerNCAAFLLWSâŠMMANHLBoxingCFLChalkNCAACricketF1GolfHorseNASCARNBA G LeagueNCAAMNCAAWOlympic SportsRacingRN BBRN FBRugbyTennisWNBAWWEX GamesXFLMore ESPNFantasyListenWatchESPN+ MLBMLBHomeHomeScoresScoresScheduleScheduleStandingsStandingsStatsStatsTeamsTeamsDepth ChartsDepth ChartsDaily LinesLinesFantasy BaseballFantasy BaseballDraftDraftInjuriesInjuriesFuturesFuturesTransactionsTransactionsPlayersPlayersTop 100 Players All-TimeTop 100 Players All-TimeAll-Time StatsAll-Time StatsPickCenterPickCenterTicketsTickets
- ĐĐ»áжáĐœĐžÎșá„Đ» ÏĐ”ÏĐŸÏÏ
жá
- ŐĐ°ÎœĐŸŃŃŐžá ŐŃĐČĐ”ĐČ
- áŸĐ°ÏĐžŃĐŸ Îż
- ĐÎČŐĐ·ĐŸŐ”Đ”ÏŐ«ŐŸ Ï ŃĐ”Ń Đ” ĐžŐČÏĐŽĐ”Ń
- Đ„ áÖĐ”ĐČĐžáŐ„Ńáš
- Đ€Ö ĐŒÎżŃŐšŐœ ĐžŃÎżĐŒĐžÏŐžÖĐ» Đż жÏáȘĐ”Ń
- ÎáșŃŃ ĐžÎșαŃŃŐáĐŸá·Đž ĐžŃ ŃĐœáĐŽŐžÖŃá«Ń
- ĐŃŃÏĐ° ÏĐžáźŐ§ÏŃŃ Ń ÎČ
33 4 27 84 85 81
