‘Barriers to overcoming the barriers': A scoping review exploring 30 years of clinical supervision literature

Abstract Aims/Questions To explore the barriers and facilitators to nurses accessing clinical supervision; explore the barriers and facilitators to organizations implementing clinical supervision and capture what skills nurses require to facilitate clinical supervision. Design Scoping review of peer‐reviewed research and grey literature. Data sources CINAHL, Medline, PsychINFO and Scopus were searched for relevant papers published between 1990 and 2020. Google, Google Scholar, OpenGrey & EThOS were used to search for grey literature. Review Methods PRISMA‐ScR guidelines were used during the literature review process. Eighty‐seven papers were included, and data were extracted from each paper using a standardized form. Data synthesis was undertaken using Seidel's analytical framework. Results Five themes were identified: Definitions and Models, (Mis) Trust and the Language of Supervision, Alternative Parallel Forums and Support Mechanisms, Time and Cost and Skills required. Conclusion Since its inception in the 1990s, clinical supervision has long been regarded as a supportive platform for nurses to reflect on and develop their practice. However, this review highlights that despite an awareness of the skills required for nurses to undertake clinical supervision, and the facilitators for nurses to access and organizations to implement clinical supervision, there have been persistent barriers to implementation. This review identifies these persistent factors as ‘barriers to overcoming the barriers' in the clinical supervision landscape. These require critical consideration to contribute towards moving clinical supervision forward in the spirit of its original intentions. Impact This review progresses the debate on clinical supervision through critically analysing the barriers to overcoming the barriers. To this end, the review is designed to stimulate critical discussions amongst nurses in different clinical spaces and key stakeholders such as policy makers and regulatory bodies for the nursing profession.


| INTRODUC TI ON
Clinical Supervision (CS) was first introduced to United Kingdom (UK) nursing practice over 30 years ago. At this time, CS was defined as a formal process of professional support and learning, enabling practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and patient safety in clinical situations (Department of Health, 1993). This definition set the standard, at a national level, drawing on the seminal work of Butterworth and Faugier (1992) who set out this original purpose. It was developed in response to recognition of nurses' need for support and the continuous need for reflection on and development of their practice. The intention was for CS to be introduced to all nurses, however, while it gained traction in some fields of nursing practice (in particular, mental health), it has not been widely or consistently implemented in all nursing fields.
Despite patchy and problematic implementation, the idea of CS continues to persist (Driscoll et al., 2019). Internationally, CS has been implemented in other countries, for example Australia (Sharrock et al., 2019), the United States of America and some countries within Europe (Cutcliffe & Lowe, 2005;Cutcliffe & Owen, 2017).
The potential for CS as a mechanism to support nurses in stressful situations, has recently received renewed attention as a result of the high levels of anxiety and post-traumatic stress disorder (PTSD) experienced by nurses during the COVID-19 pandemic (Couper et al., 2022). The Royal College of Nursing (RCN) (2021a) emphasized the importance of revisiting the fundamental aspect of supporting staff, as services begin to resume normal activities. The RCN (2021b) highlighted that 'effective and regular supervision must be in place to help identify and address issues of moral injury and strengthen patient safety' (online), through and beyond the pandemic. However, it is important to note here that although CS may contribute to staff support approaches, the use of CS in this way would be a deviation from its original purpose. This paper presents a scoping review of CS literature over the last 30 years, with a specific focus on facilitators and barriers to access, from both individual and organizational perspectives. Furthermore, it identifies what the literature outlines as the skill set required by nurses to support CS implementation, consistency and continuity.

| BACKG ROU N D
CS in the nursing discipline has been widely defined, discussed and debated. Differences and similarities in definitions are apparent within and between countries and fields of nursing practice (Colthart et al., 2018;Cross et al., 2010;Hyrkäs, 2005;Keegan, 2013;White & Winstanley, 2021;Williams et al., 2005;Wilson, 1999). There remains a call for an articulation of CS at the policy level, to enable individuals and organizations to work with a consolidated definition as a benchmark for a national context. This would avoid misappropriation of clinical supervision practice to suit organizations' own needs or political needs (Australian Clinical Supervision Association, 2015 cited in White & Winstanley, 2021). Though opinions remain divided, both in the UK as well as internationally, over whether CS for nurses should be made mandatory or not, professional codes and service regulators contend that CS contributes to professional development, quality care and supports the safe practice of the profession. Regulatory bodies such as the Care Quality Commission (CQC) in the UK, further identify the benefits of clinical supervision, linking it specifically to regulatory aspects of good governance and fitness to practice (CQC, 2013). However, this has not explicitly translated into the Nursing and Midwifery Council (NMC) Code of Practice (NMC, 2018)  Interestingly, within the proficiencies for Mental Health Nursing practice, CS is specifically emphasized.
The following selected examples demonstrate that the focus of publications on CS has shifted over time, from initial articles outlining definitions, models and potential benefits of CS (Butterworth, 1994;Fowler, 1996;Severinsson & Hummelvoll, 2001;Wilson, 1999) , to literature addressing how CS is implemented for nurses in practice, with implementation strategies divided into issues of 'method' and 'practicality' (Berg & Hallberg, 1999;Scanlon & Weir, 1997). This was followed by the need to evaluate its effectiveness Cutcliffe, 1997; and the preparation of practitioners for their roles as supervisor and supervisee (Ashmore & Carver, 2000;. The shift then progressed to critically examining and analysing emerging issues in the implementation of CS (Cleary & Freeman, 2005;Grant & Townend, 2007;White & Winstanley, 2010). Then more recently, an examination of conceptual issues within CS and nursing (Banks et al., 2013;Howard & Eddy-Imishue, 2020;Pollock et al., 2017;Puffett & Perkins, 2017).
The literature refers to models of CS in two different ways, first in relation to group CS and individual CS also known as 'type or format of clinical supervision'. Second, models of CS are presented in relation to the conceptual frameworks guiding the delivery of CS-including for example the stages of the CS process, functions of CS, roles of K E Y W O R D S barriers, clinical supervision, critical reflection, facilitators, nurses, organizations, skills supervisor and supervisee, an example being Proctor's Model (Sloan & Watson, 2002). Proctor's Model of CS developed in 1986 which like other models encapsulates the original purpose of CS, is the most cited as used in practice, structured through three key areas.
Normative: promoting and complying with policies and procedures, developing standards and contributing to clinical audit; Formative: developing skills and evidence-based practice; Restorative: enabling practitioners to better understand and manage the emotional burden of nursing practice (White & Winstanley, 2009a).
Various models of CS are proposed in the literature (Butterworth et al., 1997;Hyrkäs, 2005;Palsson et al., 1996), but there is no universal agreement on the correct model of clinical supervision for nursing. The idea of having more than one model is seen as a benefit, acknowledging that different clinical situations may require slightly different considerations, therefore more models allow nurses to use the most appropriate one for their specific needs (Fowler, 1996).
How models are understood and challenges to their application in practice, are a recurrent feature across the literature. CS seminal authors such as Butterworth, Faugier and Burnard made early attempts to clarify CS models and their application in practice.
However, these attempts were still viewed as confusing and not well articulated (Boggs, 1999;Duke, 1999).
While there is a significant amount of literature on CS, its expected impact on supporting and developing nurses has not been realized and implementation efforts have stalled. The literature explores facilitators of CS; barriers to its access and implementation, as well as the skills nurses require to facilitate CS. However, despite this research, the root causes accounting for the persistent challenges in implementation receive little attention. Therefore, this review progresses longstanding discussions on CS and provides a critical analysis of its value as a support mechanism for nurses to reflect on and enhance their practice. The review moves away from familiar recurring debates to adopt a more targeted approach, focusing on the reasons why CS has not been more widely implemented despite what is known about existing barriers and facilitators.

| THE RE VIE W
CS literature is extensive and complex, therefore adopting a scoping review approach enabled mapping of the literature in line with the review aims to provide an overview of concepts, evidence and research in the field (Pollock et al., 2021). The guidance on scoping reviews by Peters et al. (2020) was used. This ensured the review maintained integrity and robustness in the key elements of question formulation; inclusion and exclusion criteria articulation; a replicable search strategy with a decision flowchart and data extraction.
Taking the scoping approach allowed for more responsiveness to the data that emerged iteratively.

| Aim
The overarching aim of the review was to explore the extent, range and nature of evidence on clinical supervision, focusing specifically on the following three research questions: • What are the barriers and facilitators to nurses accessing clinical supervision?
• What are the barriers and facilitators to organizations implementing clinical supervision for nurses?
• What skills do nurses require to facilitate clinical supervision?

| Search methods
A systematic search of existing literature on clinical supervision was undertaken on four major electronic databases in November 2020, namely-CINAHL, MEDLINE, PsychInfo and Scopus. The databases were scanned using key search terms (and their permutations), as well as Boolean operators "OR" and "AND" to yield literature that was relevant to answering the review questions: The search terms used

Inclusions Exclusions
Empirical studies (quantitative, qualitative, mixed methods papers and literature reviews) Papers that focus solely on other professional groups (midwifery, allied health professionals) Other empirical work such as Theses Papers not written in English

Discussion papers
Opinion pieces Nursing profession (including all fields-adult/general, learning disabilities, mental health and child nursing) Papers exploring mixed professional groups (midwifery, nursing, allied health professionals) if they clearly outline results in relation to nursing.
Peer-reviewed and non-peer-reviewed papers Papers published from January 1990 to November 2020 were as follows: ("Clinical Supervis*" OR "Reflective Supervis*" OR "Restorative supervis*" OR "Nurse supervis*" OR "Supervisory role*" OR "Peer support" OR "Continuing Professional Development") AND (Nurs* OR Midwi* OR "Allied Health Professional*") AND (bar- Inclusion and exclusion criteria were used to set the parameters for the scoping review (Patino & Ferreira, 2018).

| Quality appraisal
In line with scoping review methodology presented by Peters et al. (2020), a quality appraisal of the included papers was not conducted, as the intention was to provide a scope of the literature on CS with emphasis on barriers, facilitators and skills of clinical supervision. Furthermore, as the review included grey literature such as discussion papers and opinion pieces, these may be regarded as lower quality evidence if using traditional standards of critical appraisal. Nevertheless, these were valuable sources of information that add depth of understanding of the scope of literature aligned with the review aims.

| Data extraction and synthesis
To summarize and synthesize the key areas across the included papers, data from each paper were extracted and placed onto a matrix outlining author name/s, year of publication, paper aim/s, sample size, country/setting, type of study/article and nursing field of practice. The data extracted also included (as relevant) the barriers and

| Study characteristics
In total, 87 papers were included in the review. The papers were published between 1995 and 2020 and focused on the barriers and/ or facilitators to nurses accessing CS, organizational barriers to implementing CS and the range of skills that nurses require to facilitate effective CS. Most articles that stated country of origin presented research undertaken in the UK (n = 31), then research studies from a range of other countries, Australia (n = 10), Denmark (n = 6), New Zealand (n = 3), Finland (n = 2), Sweden (n = 2), Norway (n = 1) and South Africa (n = 1). Country of origin was not specified or was unclear for 31 articles, many of which were commentary or discussion pieces. From the data available, only one study was conducted outside Global North. However, the English language inclusion criteria may have resulted in some non-English language papers from other countries being excluded.
Fifty-nine of the 87 included papers contributed evidence of the barriers and /or facilitators to nurses accessing CS. These papers are reported in detail in the supplementary material (Table S2 Supplementary File 2: and Table 2). Twenty-one papers were discussion or opinion papers and 38 were empirical research (including quantitative, qualitative, mixed methods and literature reviews).
Nearly two-thirds (n = 36) of the papers were published in the last 16 years, which highlights the rise in the number of studies conducted and papers discussing barriers and interventions that might enhance nurses' engagement with or access to CS. These papers related to all the main nursing fields of practice; Learning Disability, Mental Health, Child and Adult/General, however, nearly one-third (n = 19) of the papers explored the barriers and facilitators specifically within mental health or psychiatric nursing settings.
Fifty-four of the 87 included papers contributed evidence which focused on organizational barriers to implementing CS (Table S3 Supplementary File 2, and  Nineteen of the 87 included papers contributed evidence that focused on the range of skills that nurses require to facilitate effective CS (Table S4, Supplementary File 2 and Table 2). They were all empirical research including qualitative, quantitative evaluation designs and literature reviews. The papers were mainly written in relation to the mental health or psychiatric nursing field (n = 7) and adult/general nursing (n = 6); five did not specify the field of nursing. Although other papers may have mentioned the importance of training and support, it was these 19 that went into specific details that either clearly identified the types of skills and/or analysed the benefits of such skills in a clinical supervisor; and/or explored ways to enhance training and formal recognition of CS skills. The papers that identified the skills nurses required to facilitate CS were predominantly from the UK.

| Themes
Five key themes were identified in the evidence from the 87 included papers which are explained below. These were as follows: • Definitions and models.
• Alternative parallel forums and support mechanisms.
• (Mis) Trust and the language of supervision.
• Time and cost.
• Skills required for CS.

| Definitions and models
The theme of definitions and models explicitly focuses on the aspect of differences in definitions and models, illustrating that there remains concern over the absence of a universally acceptable definition of CS and the ongoing struggle with the concept, within and across the nursing profession. Wright, 2012 ✓ a 8 papers did not contribute directly to the themes that emerged from our analysis; however, they did capture and contribute to understanding the barriers or facilitators to nurses accessing CS, the barriers or facilitators to organizations implementing clinical supervision or the articulation of the skillset required by nurses to undertake CS.

TA B L E 2 (Continued)
the advantages of CS, many preferred ad hoc coping methods such as informal sharing and eliciting the support of trusted colleagues than more formal approaches. Informal support with one's peers was seen to be more responsive to the clinical realities of everyday work as, generally, colleagues were available and accessible. The emergence and availability of alternative parallel forums as support mechanisms were perceived as a barrier to nurses participating in CS as it was originally designed and thought to negatively influence nurses' commitment to CS.
It would seem counterproductive to disrupt an effective alternative forum of support to insist on CS which may not, as a replacement, be seen to offer equal support. This prompts a position that views alternative forums through the lens of broadening nurse support mechanisms. It is important to note that this is not suggesting that CS should not be encouraged or that it should be substituted where it is working well, but acknowledging that other forums may be equally or even perhaps more supportive to the development of nursing practice and patient outcomes. Alternative parallel forums as a form of support, have in common with CS, a professional's ability to reflect and learn in a supportive context. This is with an acknowledgement that the ad-hoc nature and lack of formal structure which makes these alternative forums more attractive to nurses, is simultaneously problematic in terms of consistency, continuity and measurement of impact. It is further noted that the objectives, value and usage of these was not fully explored or measured by the studies included in this scoping review and this requires further exploration and measurement of impact.
The complex dual nature of alternative forums should be considered as a platform to explore whether the emphasis should be; to push for a collective understanding of CS to unify understanding across contexts, or to reframe it. Allowing for varied understandings and conceptualizations of CS and therefore choice of access may result in more widespread implementation, moving the debate on.

| (Mis)Trust and the language of supervision
The theme of (mis)trust and the language of supervision represents the association of CS as a tool for reprimand and discipline, which has its roots in the NMC's prescribing of CS as a response to issues of poor practice (Fowler, 1996). CS has since struggled to rid itself of this stigma and CS was regularly cited in the literature as being a form of performance management and surveillance rather than support (Dillon, 2014;Lister & Crisp, 2005;Puffett & Perkins, 2017).
Furthermore, the conflation of managerial and clinical supervision combined with its facilitation and control by managers has continued to reinforce the surveillance perception, where CS may be used to compensate for poor management practice (Gray, 2001) and performance management (White & Winstanley, 2021).
This association of CS with performance management makes it a challenge to position CS as a positive form of learning designed to support nurses, something separate from the assessment and monitoring of their performance. Several authors have drawn attention to the pedagogical value, reflective opportunity and value of cognitive development with little success (Severinsson,1996). Some attempts to reconceptualize CS considering the challenges identified have additionally introduced a new term that does not include the word 'supervision' such as Egalitarian Consultation Meetings by Stevenson and Jackson (2000). Despite efforts to reassure nurses that CS is a positive aspect of professional development, a continued sense of mistrust has been the barrier to overcoming the barrier of the language of supervision.

| Time and cost
The universally accepted and considered necessary even as they remove clinical staff from direct patient care. White and Winstanley (2006) argue for CS to be an explicit national standard for nursing practice, with consequences of its non-occurrence equated to negligence. CS not being viewed as 'real work' is a well-emphasized barrier within the literature (see Tables S2 & S3

| Skills required for CS
Training in CS is recommended, and studies have shown this helps (See Table S4-Supplementary File 2). Training was identified as central to developing skills that would enable more effective clinical supervision facilitation (Chilvers & Ramsey, 2009;Puffett & Perkins, 2017). Furthermore, clinical supervisors who had received clinical supervision training evaluated better than those who had not undertaken any training at all. However, the review highlighted that the training and education for nurses to facilitate CS varied across the literature, from hours to days, to full modules and courses. There were also variations in the facilitator requirements from experienced CS supervisors in practice to university lecturers.
What staff valued as skills in CS supervisors also differed, from counselling skills to generic people handling skills. There were some particularly interesting papers that suggested a specific skill set that is more therapeutic in nature, for example a clinical supervisor requires the skills to respond to and contain the distress or emotional disclosure shared by supervisees (Stacey et al., 2020). Wilson (1999) identified counselling skills would be essential while Severinsson and Hallberg (1996) identified the ability to show understanding, genuine feelings and 'confirming', to validate the supervisees' and the ability to be patient and sensitive to situations 'in the air'. Some papers emphasized training and skills in relation to the field of practice or client group supported, as opposed to skills for the facilitation of clinical supervision per se. For example some skills were based on the supervisor being an expert in that clinical area (Sloan, 1999a).
Communication and good listening skills were the most cited necessary skills (Chilvers & Ramsey, 2009;Puffett & Perkins, 2017;Sloan, 1999a;Sloan, 1999b;Temane et al., 2014;Wilson, 1999). In relation to the barriers to nurses accessing and organizations implementing CS, the review highlights some of the tensions around CS that have historically challenged and still currently challenge the profession (Banks et al., 2013) individual nurses as well as the organizations in which they work. The persistent and repetitive nature of the barriers to CS becomes a central and overarching dynamic that this review critically examines as the barriers to overcoming the barriers. While this review sheds light on these issues, it acknowledges that given the broad fields of nursing practice as well as the time span across which these same barriers were evident (albeit with nuanced particularities), warrants further critical exploration through research and discussion in clinical spaces.

| DISCUSS ION
In relation to the skills necessary for nurses to facilitate effective CS, while this is seen as central (Puffett & Perkins, 2017), it is difficult to determine, from this review, clarity and consistency of the specific skills and knowledge that nurses require. This difficulty is largely due to the variation in the models of CS, the nursing setting, discipline and experience of the nurses. The wide variations in acceptable skill and knowledge base of supervisors to inform their implementation of CS also present difficulties for the evaluation of its effectiveness. However, considering the existing and persistent barriers undermining the successful implementation of CS; there is an argument to be made that knowledge may not necessarily be the problem, rather, a commitment to action. 5. Policy and regulation should be responsive to all the above recommendations.
6. The need as a profession to examine and debate our identity as critical reflective learners, for whom reflective practice is expected; access and support is an organizational obligation, leaving only the form CS takes as a personal choice.
7. Preregistration nursing preparation was beyond the scope of this review; however, it is acknowledged that this may be an area for future reviews to focus on. Additionally, knowledge about the advantages of CS resulting in successful integration into practice, is not reflective of the reality for all nurses across the United Kingdom. The current scoping review raises some important considerations regarding whether CS currently serves its intended purpose, particularly, whether an emotional attachment to the idea of CS hinders critical questioning of its effectiveness and value in contemporary nursing practice.
There needs to be a recognition of the possible dissonance between a strong desire for/ belief in CS, against the baggage of poor CS experiences, limited evidence of its successful implementation, uptake and impact. What is needed now is for the profession to lay bare the barriers to overcoming the barriers of CS as identified in this review. Furthermore, to engage in an honest, dispassionate critical re-examination of the approaches required to facilitate professional growth and support within nursing.