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Routledge Handbook of Clinical
Supervision

The Routledge Handbook of Clinical Supervision provides a global ‘state of the art’ over-
view of clinical supervision, presenting and examining the most comprehensive,
robust empirical evidence upon which to base practice.
This authoritative volume builds on a previous volume, Fundamental Themes in
Clinical Supervision, whilst greatly expanding its coverage. It contains ten updated
and 23 entirely new chapters, focusing on both areas of contemporary interest and
hitherto under-­examined issues. Divided into five parts, it discusses:

• education and training

• implementation and development
• experiences and practice
• research activity
• international perspectives

Containing chapters on Europe, the US, Canada and Australasia, the Routledge
Handbook of Clinical Supervision has a multi-­disciplinary approach to clinical super­
vision and includes chapters relevant to nurses, doctors, psychologists, psychiatrists
and counsellors. It will be of interest to students, researchers and practitioners of
clinical supervision in a range of health professions.

John R. Cutcliffe is Acadia Professor of Psychiatric and Mental Health Nursing at

the University of Maine, US. He is also Adjunct Professor of Nursing at the Univer-
sity of Ulster, UK and the University of Malta, the Associate Editor (Americas) for
the International Journal of Mental Health and an Assistant Editor for the International
Journal of Nursing Studies.

Kristiina Hyrkäs is Director of the Center for Nursing Research and Quality Out-
comes at Maine Medical Center and Adjunct Professor of Nursing at the University
of Southern Maine, US. She is also the Editor of the Journal of Nursing Management.

John Fowler is Principal Lecturer in the School of Nursing and Midwifery at De

Montfort University, UK. He has held recent joint appointment posts as an educa-
tional consultant and undertakes a number of consultancy posts with the NHS and
the independent sector.
Routledge Handbook of
Clinical Supervision
Fundamental international themes

Edited by John R. Cutcliffe,

Kristiina Hyrkäs and John Fowler
First published 2011
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
Simultaneously published in the USA and Canada
by Routledge
270 Madison Avenue, New York, NY 10016
Routledge is an imprint of the Taylor & Francis Group, an informa business
This edition published in the Taylor & Francis e-Library, 2010.
To purchase your own copy of this or any of Taylor & Francis or Routledge’s
collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.
© 2011 John Cutcliffe, Kristiina Hyrkäs and John Fowler for selection and
editorial matter, and John Cutcliffe, Tony Butterworth and Brigid Proctor for
selection of those chapters which originally appeared in Fundamental Themes of
Clinical Supervision; individual contributors, their contributions
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the
publishers.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Routledge handbook of clinical supervision: fundamental international themes/
edited by John Cutcliffe, Kristiina Hyrkäs, and John Fowler.
p. cm.
Other title: Handbook of clinical supervision
Includes bibliographical references.
1. Nurses–Supervision of. I. Cutcliffe, John R., 1966– II. Hyrkäs, Kristiina.
III. Fowler, John, RGN. IV. Title: Handbook of clinical supervision.
[DNLM: 1. Administrative Personnel. 2. Organization and Administration.
3. Clinical Competence. 4. Evidence-­Based Practice. 5. Internationality.
6. Leadership. W 88 R869 2011]
RT86.45.R68 2011
362.17'3068–dc22 2010010178

ISBN 0-203-84343-6 Master e-book ISBN

ISBN13: 978-0-415-77955-5 (hbk)

ISBN13: 978-0-203-84343-7 (ebk)
This book is dedicated to all those whom we have encountered and work with on
our individual clinical supervision journeys.
To Tony and David, we offer our thanks for your fine forewords and the work you
have already done in clinical supervision.
And, from John Cutcliffe to my youngest daughter Charlotte Holly, this one is for
you.
Contents

List of illustrations xi
Notes on editors and contributing authors xiii
Foreword I xxi
Foreword II xxiii
Preface xxv

1 Introduction: global perspectives on fundamental themes in

clinical supervision 1
J ohn R . C utcliffe , K ristiina H yrk ä s and J ohn F owler

2 Clinical supervision: origins, overviews and rudiments 8

J ohn F owler and J ohn r . C utcliffe

Part I
Education, training and approaches to clinical supervision 21

3 Training for the supervision alliance: attitude, skills and

intention 23
B rigid P roctor

4 An alternative training approach in clinical supervision 35

J ohn r . C utcliffe

5 Experiential learning: an underpinning theoretical perspective

for clinical supervision 51
J ohn F owler

6 Clinical supervision: visions from the classroom 63

M ike E pling and P aul C assedy

7 Training requirements for clinical supervision in the

United Kingdom 79
G raham S loan and mick fleming
viii   Contents
8 Postmodernising clinical supervision in nursing 93
C hris S tevenson

9 Solution-focused clinical supervision: using solution-focused

techniques within clinical supervision 102
J ohn F owler

Part II
Introducing, implementing and developing clinical supervision 111

10 Clinical supervision and clinical governance 113

V eronica B ishop

11 Implementing clinical supervision in a National Health Service

Community Trust: sharing the vision 125
J enny B ennett , B ob G ardener and F iona J ames

12 Clinical supervision in the United Kingdom – ten years on:

a review of the United Kingdom clinical supervision literature 136
G raham S loan

13 Implementing clinical supervision: case studies from

Leicestershire, United Kingdom 148
J ohn F owler

14 Clinical supervision: an overview of the ideas and some

requirements for professional practice 157
A lun charles J ones

15 Introducing clinical supervision in a rural health care

organisation: an Australian experience 163
L isa L ynch , B renda H appell and K errie H ancox

Part III
The practice and experience of clinical supervision 175

16 Clinical supervision: my path towards clinical excellence in

mental health nursing 177
P aul S mith

17 Supporting palliative care nursing: the roles of clinical

supervision 186
A lun C harles J ones

18 Clinical supervision for United Kingdom medical professionals 196

H elen H alpern
 Contents   ix
19 Providing cross-­discipline group supervision to new supervisors:
challenging some common apprehensions and myths 208
P aul C assedy , M ike E pling , L i z W illiamson and G ale H arvey

20 The realities of clinical supervision in an Australian acute

inpatient setting 218
M ichelle C leary and J an H orsfall

21 Clinical supervision for nurse educationalists: personal

perspectives from a postgraduate mental health nursing course 226
P eter G oward , J oe K ellett and J ohn W ren

Part IV
Contemporary research activity on clinical supervision 239

22 Nurses’ experiences of core phenomena in the supervisor

training programme 241
A nn - ­K ristin H olm W iebe , I ngrid J ohansson ,
I ngegerd L indquist and E lisabeth S everinsson

23 Efficacy of clinical supervision: influence on job satisfaction,

burnout and quality of care 250
K ristiina H yrk ä s , K aija A ppelqvist - ­S chmidlechner and
R iina L emponen

24 Multidisciplinary attitudinal positions regarding clinical

supervision: a cross-­sectional study 261
J ohn r . C utcliffe and K ristiina H yrk ä s

25 Clinical supervision in multidisciplinary groups: qualitative

evaluation using a focus group technique 277
J ames D ooher and J ohn F owler

26 Clinical supervision for nurses in administrative and leadership

positions: a review of the studies focusing on administrative
clinical supervision 289
P irjo S irola - ­K arvinen and K ristiina H yrk ä s

27 Personal, professional and practice development: case studies

from clinical supervision practice in psychiatric/mental
health nursing 300
J ohn r . C utcliffe
x   Contents
Part V
International perspectives and developments in the state of the
science of clinical supervision 315

28 The state of the science of clinical supervision in Australia and

New Zealand 317
L isa L ynch , K errie H ancox and B renda H appell

29 The state of the science of clinical supervision in Europe 327

I ngela B erggren and E lisabeth S everinsson

30 The state of the science of clinical supervision in the

United States: a social work- and nursing-focused perspective 338
C arlean G ilbert and J ohn r . C utcliffe

31 Clinical supervision in Canada: bridging the education-­to-practice

gap through interprofessional supervision and lateral mentoring –
a value-added approach to clinical supervision 353
N ancy A rthur and S helly R ussell - ­mayhew

32 A comparison of US and European conceptualisations of

clinical supervision 364
J ohn r . C utcliffe

33 Clinical supervision for the twenty-­first century and beyond:

successes, challenges and the road ahead 374
J ohn r . C utcliffe and J ohn F owler

Index 395
Illustrations

Figures
2.1 Four common terms found in the nursing literature and their
relationship to/with clinical supervision 11
3.1 Supervision: alliance towards reflective practice 24
5.1 Experiential learning underpinning clinical supervision 57
5.2 Experiential learning underpinning clinical supervision with
experience and reflection 58
5.3 Limited experiential learning/clinical supervision 58
5.4 Limited reflection in experiential learning supervision 59
5.5 Limited experience in experiential learning/supervision 59
5.6 Factors influencing experiential learning 60
6.1 A training model for learning and development in clinical
supervision 65
7.1 Postgraduate Diploma/MSc programme structure 87
10.1 Convergence model of clinical supervision 118
13.1 Example of reflective writing 155
15.1 The Lynch Model of implementation 170
18.1 The domains of supervision 197
18.2 Model of learning to facilitate supervision 204
23.1 Study design and theoretical framework of the study 253
24.1 Respondents/supervisees 265
26.1 Three main elements and functions of clinical supervision 291
26.2 Stages of the original search strategy and evaluation of the
references 292
27.1 Personal, professional and practice development: the effect of
receiving clinical supervision on the practice of mental health nurses 308

Tables
6.1 Supervision statements: descriptive statistics showing the maximum/
minimum scores including the mean and standard deviation for each
ranked statement 71
15.1 Implementation process: stages and influencing factors 165
18.1 Examples of the reading 203
xii   Illustrations
24.1 Mode values of the ranks concerning the characteristics of clinical
supervision 266–267
24.2 Agreement percentages concerning the rankings of the items within
the groups and among all supervisees 269
24.3 Comparison of the mean ranks concerning the characteristics of
clinical supervision 270

Boxes
3.1 Values and assumptions of the Supervision Alliance Model 24
3.2 Supervision skills for helping practitioners reflect, learn and change 28
3.3 Guidelines and methods for facilitating the development of
supervisors and practitioner/supervisees 29
3.4 Experiential portrayal of the Supervision Alliance Model 31
3.5 Experiential and creative activities 31
4.1 Reported benefits of clinical supervision 36
4.2 Reasons for resisting clinical supervision within nursing 38
4.3 Advantages of nurses being supervisees 40
6.1 Some examples taken from the behavioural observation statements 72
7.1 Half-­day training for supervisees 83
7.2 Overview of training programme for clinical supervisors 85
7.3 Session 2 of training programme for clinical supervisors 86
7.4 Learning outcomes for clinical supervision module 89
10.1 Donabedian’s seven pillars of quality 117
10.2 Organisational requirements that are essential for the successful
implementation of clinical supervision 122
11.1 Identified stages of the planning process 126
11.2 Examples of barriers to change 134
12.1 The UKCC’s six key statements 137
12.2 Revisiting the UKCC’s six statements 144
21.1 Process model of supervision 229
24.1 Group Supervision Ranking Form 264
26.1 The databases and selected journals used in this literature review 293
27.1 Hierarchy of evidence 301
32.1 Key questions arising out of a comparison of European and
United States conceptualisations of clinical supervision 365
Editors and contributing authors

John R. Cutcliffe RMN, RGN, RPN, RN, BSc(Hons)Nrsg, PhD holds the Acadia Pro-
fessor of Psychiatric and Mental Health Nursing chair at the University of Maine,
United States, and a joint appointment at Acadia Psychiatric Hospital; the first
and only psychiatric facility in the world to achieve ‘Magnet status’. He also holds
Adjunct Professor of Nursing positions at the University of Ulster, United King-
dom and the University of Malta. John’s clinical background is in nursing, having
completed his psychiatric nurse education and then his general nurse education
in the United Kingdom. He is an international scholar having worked in univer-
sities in four different countries – England, Northern Ireland, Canada and the
United States.
John’s research interests focus on hope, suicide and clinical supervision and
in 2003 he was recognised by the federal government of Canada and cited as one
of the top 20 ‘Research Leaders of Tomorrow’ for his research. In 2004, he was
nominated for a Canadian Research Chair and was given the highest research
rating ‘outstanding’ from the independent reviewers. He has published exten-
sively – over 150 papers and nine books – and has over $4,000,000 dollars of
extra-­mural research funding as Primary/Co-­Investigator. He is currently working
with colleagues from the University of Toronto (Canada), Dublin City University
(Ireland) and the University of Ulster (UK) on an international programme of
research focusing on suicide in young men.
John’s interest in clinical supervision began during his mental health nurse
education/training in 1987, where he was fortunate enough to receive supervi-
sion during his training. Since then, in whatever the area/speciality of his prac-
tice, he has received and/or provided clinical supervision. He has provided
supervision to various grades of nurses since 1990, and provided ‘train the
trainer’ clinical supervision training to a wide variety of different health care pro-
fessional groups and in different parts of the world. He has recently served as
the Director of the International Society of Psychiatric Nurses: Education and
Research division; he is an Associate Editor for the International Journal of Mental
Health and an Assistant Editor for the International Journal of Nursing Studies; in
addition to sitting on the editorial boards of six other health care-­focused jour-
nals. He retains his interest in clinical work, particularly around care of the clini-
cal supervision, care of the suicidal person, inspiring hope and more broadly in
psychiatric nursing. He is married with two children.
xiv   Editors and contributing authors
Kristiina Hyrkäs PhD, LicNSc, MNSc, RN is currently the Director of the Center for
Nursing Research and Quality Outcomes (CNRQO) at Maine Medical Center.
Kristiina’s clinical background has specialised in surgical and oncology nursing.
She has worked at the University of Tampere, Finland, as a Planning Officer,
a Senior Lecturer, Senior Assistant Professor in the Department of Nursing
Science and a full time researcher. Kristiina has worked as an Assistant Profes-
sor at the University of Alberta, Faculty of Nursing and Associate Professor at the
University of Northern British Columbia. Since moving to Maine, Kristiina has
been appointed as Adjunct Professor of Nursing at the University of Southern
Maine.
Kristiina has conducted pioneering empirical research on clinical supervi-
sion. She has published scientific articles on such topics as: (1) effects of clini-
cal supervision on quality of care; continuous quality improvement through team
supervision; nurse managers’ perceptions of promotion of quality management
through peer supervision; (2) cost-­benefit analysis of team supervision; (3) expert
supervisors’ views of promoting and inhibiting factors on multi-­professional team
supervision; (4) team members’ perceptions of the effects of multi-­professional
team supervision; (5) first-­line managers’ perceptions of the long-­term effects
of clinical supervision; (6) clinical supervision for nurses in administrative and
leadership positions; (7) translating and validating an evaluation instrument for
clinical supervision; (8) municipal elected officials’/municipal managers’ percep-
tions of clinical supervision; (9) clinical supervision, burnout and job satisfaction
(national study); (10) clinical supervision, burnout and job satisfaction in mental
health and psychiatric nurses.
Kristiina is an editorial board member for the Journal of Nursing Management
and has been an Editor of this journal since January 2008. Kristiina also co-­chairs
the publication committee of the INDEN (International Network for Doctoral
Education in Nursing) newsletter. She is also a member of Sigma Theta Tau and
Eastern Nursing Research Society (ERNS)/Membership Board member.
John Fowler PhD, MA, BA, DN, Cert Ed, RGN, RMN, RCNT, RNT trained as a gen-
eral nurse and then as a psychiatric nurse in Portsmouth, England, in the 1970s
and has subsequently been working in nurse education for over 25 years.
He is currently Principal Lecturer at De Montfort University Leicester. Until
recently he held a joint appointment as Educational Consultant with Leices-
ter City PCT. John has had a long academic and an applied interest in clinical
supervision and in 1998 was one of the first people to publish a handbook on
clinical supervision. He has continued to advise and evaluate clinical supervision
programmes in the UK. He has published over 50 journal articles/book chap-
ters and edited five textbooks, and is series editor to the Fundamental Aspects of
Nursing Series (Quay Books). John is a volunteer tutor with PRIME (Partnerships
in International Medical Education) and has had two short placements in Nepal.
He is a regular presenter of BBC’s Radio Leicester’s ‘Thought for the Day’ and is
married with four children.
Nancy Arthur is Professor and Canada Research Chair in Professional Education,
Division of Applied Psychology, Faculty of Education, University of Calgary. Nan-
cy’s teaching and research interests include multicultural counselling and super-
vision, career development, and interprofessional practice. Nancy was one of the
 Editors and contributing authors   xv
principal investigators for a Health Canada-­funded study of lateral mentoring
and interprofessional practice. Nancy is also a Registered Psychologist.
Kaija Appelqvist-­Schmidlechner, MA is a Researcher at the National Institute for
Health and Welfare, Finland. Kaija has studied communication science, psychol-
ogy and sociology at the University of Salzburg, Austria. Since 1999, she has been
working as a Researcher, first in the department of nursing science at the Univer-
sity of Tampere in Finland, then in the Research Centre for Social and Health
Care at Seinäjoki University of Applied Science and presently in the National
Institute for Health and Welfare. Her interest in clinical supervision is directed
at evaluation of the effects and facilitative factors of clinical supervision in health
care. Furthermore, Kaija has been interested in validating research instruments
for clinical supervision and examining the municipal policymakers’ views of clini-
cal supervision.
Jenny Bennett, Bob Gardener and Fiona James. At the time of writing Bob Gar-
dener, RGN, MA, CPN Cert, IHSM (postgrad cert), was lead professional for
mental health nursing, Fiona James, RGN, HV, BN, MSc, was lead professional,
health visiting and community health care service, and Jenny Bennett, RGN, was
lead professional for community hospital nursing. These three authors are all
based at North Derbyshire Community NHS Trust. As a team they have facilitated
the implementation of clinical supervision in their disciplines. Part of their work
has been to develop a five-­year multi-­disciplinary strategy for the implementation
of clinical supervision across the organisation. They have designed, organised
and facilitated clinical supervision awareness training for supervisors and supervi-
sees for various disciplines. At present they all receive clinical supervision and are
supervisors for individuals and groups in the Trust.
Ingela Berggren RN, RTN is Senior Lecturer at the Department of Nursing, Health
and Culture at University West, Trollhättan, Sweden. Her background is as an
intensive care nurse and lecturer in nursing education at basic as well as advanced
levels. Her research focuses on the nursing profession, in particular supervision
and ethical decision making.
Veronica Bishop PhD, MPhil, RGN, FRSA is Visiting Professor of Nursing at City
University, London, and is Editor-­in-Chief of the research and development jour-
nal, Journal of Research in Nursing. She is also a board member of the Hong Kong
nurses’ journal; for 12 years was a member of the scientific committee for the
RCN Research Society and for 11 years served as an executive member of the
Florence Nightingale Foundation and a member of its academic panel. Veronica
was the national UK lead on clinical supervision. Veronica has worked as a con-
sultant for the WHO in Denmark, India and Romania. She is widely published
and has presented keynote speeches at numerous nursing conferences. She has
recently been involved with the implementation of clinical supervision in the
prison services and remains committed to its effectiveness in supporting staff in
the provision of quality care.
Paul Cassedy RMN, Cert Ed, RNT, Dip Humanistic Psychology, MA is a Mental
Health Lecturer at the University of Nottingham and teacher to the clinical
supervision course in the School of Nursing. As a counsellor, he receives both
xvi   Editors and contributing authors
individual and group supervision. He also provides supervision for health care
staff who have a counselling role, and new supervisors within an adult nurse
setting.
Michelle Cleary, RN, PhD is Associate Professor (Mental Health Nursing) at the
School of Nursing and Midwifery, University of Western Sydney, Australia.
Michelle has published over 90 academic papers (many as lead author) and her
research areas include clinical innovation, health service evaluation, leadership,
nurse education, ethics, outcome measurement, h-­index, consumer and carer
issues (including stigma), bullying and delivering difficult news. Michelle led an
international Cochrane Systematic Review team evaluating psychosocial interven-
tions for people with both severe mental illness and substance misuse. Michelle is
also on the editorial board of the International Journal of Mental Health Nursing.
James Dooher RMN, MA, FHE Cert, Dip HCR is Principal in Mental Health Nursing
at De Montfort University, Leicester. James maintains an active involvement in
the practice of clinical supervision through his clinical work. He promotes its fur-
ther development in both educational and practice settings. James has published
widely on mental health issues and is particularly interested in the ‘power’ rela-
tionship. He is currently undertaking further research in this area.
Mike Epling RMN, FETC, Cert Ed (HE/FE) RNT, Dip Ed Counselling, M Ed is
­Lecturer in Mental Health at the University of Nottingham. Mike is a teacher to
the clinical supervision course in the School of Nursing. He is involved in provid-
ing supervision to staff within health care settings and counselling settings, as well
as providing supervision to groups of supervisors.
Mick Fleming, RMN, MA, BA, YCAP is Lecturer in Mental Health and Programme
Leader for the MSc/Postgraduate Diploma in Psychosocial Interventions at the
University of the West of Scotland. He has published in the field of psychosocial
models of schizophrenia and the evaluation of psychosocial intervention training.
His research interests include non-­biological models of psychosis, validity of the
schizophrenia concept and developments in the training of psychosocial inter-
ventions. He is a previous winner of the Foundation of Nursing Studies – Jack
Mallabar Award – for his work introducing evidence-­based psychosocial interven-
tions into an inpatient mental health unit.
Carlean Gilbert is Associate Professor on the faculty of the School of Social Work,
Loyola University Chicago, following 17 years of experience as a pediatric social
worker. Her areas of scholarship focus on clinical supervision, health and mental
health issues of children and adolescents, the impact of childrens’ illnesses on
family systems, group therapy, and the role of spirituality and religion in clinical
practice. Carlean is editor of The Clinical Supervisor: An Interdisciplinary Journal of
Theory, Research, and Practice and member of the editorial board of Social Work in
Health Care. She has been elected to the Case Management Certification Board
of the American Case Management Association and Board of Directors of the
Society for Social Work Leadership in Health Care. Carlean is a Licensed Clinical
Social Worker and a Certified Group Psychotherapist.
Peter Goward RMN, RNT, MSc. At the time of writing Peter was Head of Depart-
ment, Mental Health and Learning Disability at the University of Sheffield. Peter
 Editors and contributing authors   xvii
is involved in student and peer clinical supervision within undergraduate and
postgraduate health-­focused programmes. He is also involved in providing super-
vision for senior trust managers and clinicians within mental health settings.
Helen Halpern MB, BS, FRCGP, MSysPsych, is a general practitioner, family ther-
apist and tutor in supervision skills in London. Helen is interested in applying
ideas from systemic family therapy and educational theory to develop a frame-
work for supervision for doctors, dentists and allied healthcare professionals that
fits the context of the busy and rapidly-­changing world of the National Health
Service in the UK. She helps to facilitate courses and workshops for the London
Deanery and at the Tavistock Clinic using a questioning approach called Conver-
sations Inviting Change. This work includes bringing supervision skills into train-
ing for clinical teachers and appraisers. She also helps to set-­up peer supervision
groups for continuing professional development and support.
Kerrie Hancox is Co-­Director of Clinical Supervision Consultants. In this role she
consults to organisations on a range of levels and provides both group and indi-
vidual clinical supervision. She also works part-­time as an Enhanced Crisis and
Assessment Clinician in an emergency department. She has been working in
psychiatry since 1985 in a wide variety of clinical settings in Australia and over-
seas. Kerrie has a Bachelor of Nursing and completed her Master in Psychiatric
Nursing in 2000. The focus of her research was clinical supervision. Kerrie also
has expertise in a range of therapeutic skills including family therapy and gestalt
therapy. She also has expertise in organisational dynamics and socioanalysis
education. Kerrie was co-­developer with Lisa Lynch of Clinical Supervision for
Health Care Professionals, and Unlocking the Secret. She remains committed to
the importance of quality education for supervisors and supervisees.
Brenda Happell is Professor of Contemporary Nursing, Director of the Centre for
Mental Health and Well-­being, and Director of the Institute for Health and Social
Science Research at CQUniversity Australia. Brenda has a long standing interest
in clinical supervision. She is co-­author of the book Clinical Supervision for Nurses
and has co-­authored a number of publications on this topic. In her former posi-
tion as the inaugural Director of the Centre for Psychiatric Nursing Research and
Practice, Brenda was responsible for identifying the need for and subsequently
overseeing the development of the subject Clinical Supervision for Health Care
Professionals and she is currently a member of the Clinical Supervision Taskforce
for Queensland Health. She is nationally and internationally recognised for her
expertise in nursing, as evidenced by invitations as a visiting scholar and pres-
entations at national and international conferences. Brenda has published pro-
lifically in nursing and related health journals and her work is frequently cited
and used to effect practice change. She is the Editor of the International Journal of
Mental Health Nursing and Associate Editor of Issues in Mental Health Nursing; and
a member of the Board of Directors of the Australian College of Mental Health
Nurses. Brenda is an Honorary Professor at the University of Alberta.
Ann-­Kristin Holm Wiebe, Ingrid Johansson and Ingegerd Lindquist are registered
nurses with MA degrees, as well as nurse supervisors. They have many years
experience of teaching future and practising nurses about nursing supervision
at the Institute of Health and Care Sciences, University of Gothenburg, Sweden.
xviii   Editors and contributing authors
Their research focus is nursing supervision. The University of Gothenburg has
highlighted the importance of supervision of the nursing process in the educa-
tion of nurses, and in 2008 the above-­mentioned nurse supervisors were awarded
the University’s pedagogical team prize for their work with nursing supervision at
the Institute.
Jan Horsfall, PhD, Research Unit, Concord Centre for Mental Health, Sydney South
West Area Mental Health Service, Concord Hospital, Sydney.
Alun Charles Jones is a specialist nurse in adult psychotherapy and a UKCP reg-
istered psychotherapist at the Betsi Cadwaladr University Health Board, the
Department of Psychological Therapies, Wrexham, Wales. Alun is also an adult
psychotherapist in the independent sector and has an interest in psychological
assessment and support for weight management surgery. Alun has experience of
developing liaison psychiatry services. As such, he has competencies concerned
with planning psychological interventions for people with physical illness. In past
years, areas of specialist practice concerned psychotherapy with the seriously ill,
the dying and bereaved, including working with people with cancer, HIV and
AIDS and cystic fibrosis in different medical settings. Alun is currently a clinical
supervisor to trainee psychotherapists of different disciplines including medicine.
Joe Kellett RMN, RGN, DN (Lond), STD, RNT, BEd (Hons), MSc (Ed Man), PgCert
(PSI). At the time of writing Joe was Senior Lecturer at the University of Shef-
field. Joe currently provides group supervision to students on the postgraduate
Pre-­Registration Diploma in Mental Health Nursing Studies. He also provides
ongoing clinical supervision to mental health nursing staff at local trusts.
Riina Lemponen MSc has worked as a biostatistician at the Tampere School of Public
Health, University of Tampere, Finland for the past ten years. She has participated
in a variety of health related studies as a statistical expert. Riina became adept with
the clinical supervision research as a part of Kristiina Hyrkäs’ and Kaija Appelqvist-
­Schmidlechner’s research initiatives at the University of Tampere. Riina’s focus in
the project was mainly on analysing and modelling the data.
Lisa Lynch is Director of Child and Adolescent Mental Health and Primary Part-
nerships at Southern Health and the Co-­Director of Clinical Supervision Consult-
ants. She has been involved with clinical supervision, as a supervisor, a supervisee,
a manager and an academic, for more than ten years. Lisa was a co-­developer
of the fully accredited Clinical Supervision for Health Care Professionals course,
and the workshop for potential supervisees, Unlocking the Secret, both intro-
duced in Victoria in 2001. These highly successful programmes were amongst the
first of their kind. Lisa has recently completed a Master of Nursing by Research;
she undertook a study of the implementation of clinical supervision in a mental
health service in Victoria. The findings from her work culminated in a model to
guide the implementation of clinical supervision within health care settings, now
known as the Lynch model. In 2008 Lisa co-­authored the popular Clinical Supervi-
sion for Nurses. This text is a very practical, hands-­on guide to understanding and
implementing clinical supervision.
David J. Powell is President of the International Center for Health Concerns. In this
role he trains worldwide on clinical supervision and addictions. He is author of
 Editors and contributing authors   xix
Clinical Supervision in Alcohol and Drug Abuse Counseling and over 200 artıcles. He
is on the editorial board of The Clinical Supervisor and four other journals. He has
trained over 10,000 clinical supervisors in over 80 countries and his three texts
on supervision are considered the standard books in the addiction field. He was
the Chair of the Treatment Improvement Protocol 52 published by the Substance
Abuse Mental Health Services Administration.
Brigid Proctor BA (Oxon), DipSocSci (Edin), CertApplSocStud (LSE) Fellow and
Accredited Supervisor, BAC. She has been Director of South West Counselling
Course Centre. She has a small private counselling practice, and a large indi-
vidual and group supervision and supervision training practice. She also does
occasional one-­off consultancy and training. She has been co-­authoring, with
Francesca Inskipp, supervision learning materials, including those referenced in
her chapter, and is co-­author of Group Supervision: A Guide to Create Practice (Sage,
London 2000).
Shelly Russell-­Mayhew is a Registered Psychologist and Associate Professor in the
Division of Applied Psychology, Faculty of Education, University of Calgary. Shelly
is currently the Co-­ordinator for the Master of Counselling (MC) Programme, a
course-­based masters programme utilising a distributed learning model. In this
capacity, she became interested in interprofessional work-­place supervision for
counselor education and training.
Elisabeth Severinsson RPN, RNT, MCSc, DrPH is Professor and Director of
Research at the Centre for Women’s, Family and Child Health at Vestfold Univer-
sity College, Tønsberg, Norway. Elisabeth has spent a number of years research-
ing different phenomena in the health care sciences, more specifically nursing
and midwifery. She has long experience of the research cultures in the Nordic
countries, Australia and Japan. Elisabeth’s research interests are wide-­ranging
and include pre- and postnatal women’s health, ethics, as well as clinical and aca-
demic supervision. Other international research interests are: research manage-
ment, research and policy, mental health, public health, nursing education and
research problems that are interesting from a methodological perspective. She
is the author of more than 190 scientific articles, reports and book chapters as
well as several books. Her engagement in international research collaboration is
extensive.
Pirjo Sirola-­Karvinen MSc, MNSc, BNSc, PHN, RN works as a Senior Specialist at
the Finnish Institute of Health (FIOH). Her current work focuses on initiatives
regarding a healthy work environment and well-­being aiming at sustainable devel-
opment and changes. Pirjo is also a doctoral student at the Department of Health
Policy and Management, Faculty of Social Sciences, University of Eastern Finland,
Kuopio. The focus of Pirjo’s doctoral thesis is clinical supervision for health care
leaders and administrators.
Graham Sloan PhD, BSc (Hons), Diploma in Nursing (London), Post-­Graduate
Diploma in Cognitive and Behavioural Psychotherapy, RMN, RGN, is a Nurse
Consultant in Psychological Therapies, NHS Ayrshire and Arran, holds a joint
appointment with the University of the West of Scotland and is a Psychological
Therapies Training Co-­ordinator with NHS Education for Scotland. He is an
xx   Editors and contributing authors
accredited psychotherapist, clinical supervisor and trainer (British Association of
Behavioural and Cognitive Psychotherapy; International Standards for Interper-
sonal Psychotherapy). He has extensive experience of supervising psychological
therapists and other mental health practitioners and has contributed to the train-
ing of a substantial number of clinical supervisors. Graham is the author of Clin-
ical Supervision in Mental Health Nursing and has numerous additional scholarly
publications on clinical supervision.
Paul Smith RGN, RMN, Dip (NS), Dip (UTR). At the time of writing Paul was a
Psychiatric Charge Nurse with Barnsley Community and Priority NHS Trust. Paul
has received and provided clinical supervision for the large majority of his nurs-
ing career. He is currently developing clinical supervision structures for his team.
Chris Stevenson RMN, BA (Hons), MSc (Dist), PhD, CPsych, is Professor and Chair
of Mental Health at Dublin City University and Visiting Professor at the Univer-
sity of Ulster. She has a cumulative grant income of C1,500,000 and her book
and paper publications exceed 70. Chris’ research interests are suicidality, family
systems/therapy, psychotherapy evaluation and clinical supervision, about which
she has published consistently over the last decade. She currently teaches MSc/
Doctorate Psychotherapy and supervises PhD students in the area of mental
health, including clinical supervision.
Liz Williamson and Gale Harvey. Liz Williamson RGN, BSc(Hons), Senior Nurse,
Surgery, Nottingham City Hospital NHS Trust; Gale Harvey RGN, BSc(Hons),
Clinical Leader, Burns Unit. At the time of writing Liz and Gale were responsible
for leading, planning and implementing clinical supervision for the Trust. This
included a comprehensive in-­house training programme, which was devised and
delivered by them.
John Wren RMN, RGN, BA (Hons), Cert Ed, PGCE. At the time of writing John was
a Lecturer in Mental Health Nursing at the University of Sheffield. He provides
clinical supervision to students on the postgraduate Pre-­Registration Diploma in
Mental Health Nursing studies. He has worked as part of a professional develop-
ment team to provide a supervision framework for a local trust.
Foreword I
Tony Butterworth

I am particularly pleased to be able to bring some of my own observations to bear at

the beginning of this important book.
My career as a clinician, educator and researcher spans forty plus years and
during that period I have witnessed significant changes and new approaches in the
delivery of care. Nonetheless, several constants have held, and continue to hold true
in the delivery of first class health care services. These can be described as:

• the appropriate delivery of thoughtful and well considered care to patients and
people who use services;
• care that sustains their dignity and safety; and
• interventions that are evidenced-based and demonstrably useful and finally
helping health care organisations to recognise their responsibilities to their
employees through supportive employee strategies.

All of these admirable principles require sustained attention and nurture and
clinical supervision stands tall amongst the most important of supportive strategies.
Sometimes, and somewhat sadly, this is where some organisations can also fall down.
I firmly believe that clinical supervision offers focus and support in ‘healthy’ organi-
sations and it has been one of my great privileges to have worked on the develop-
ment of clinical supervision as an educator and researcher throughout most of my
career. As my energies begin to be directed elsewhere it is so heartening to see
others carry forward this important work and no more so than through the descrip-
tions and accounts to be found in this book.
In 1992 my coflfleagues and I at the fin the UK offered
the very first published textbook to describe the principles and practice of clinical
supervision and mentorship in nursing (Butterworth and Faugier 1992). Since then,
the term ‘clinical supervision’ has entered the language of our profession in a way
that was inconceivable those several years ago and this book bears testimony to that
significant change. For some practitioners clinical supervision remains words alone.
Some organisations have not chosen to provide the necessary expertise and organi-
sational time to develop the necessary platform for clinical supervision, and it is to
their great discredit that this is so. A little later in my career my research team and I
at the University of Lincoln reviewed the clinical supervision literature (Butterworth
et al. 2008) in order to determine what progress if any could be seen in an identifia-
ble time period, and through that progress identify the major themes that were
emerging from research and practice. Several themes presented themselves.
xxii   Foreword I
Although as we suggested there were some rather tired often repetitious discussions
in the literature it was clear that some of the most interesting work beginning to
emerge (Bradshaw et al. 2007) was that of describing the impact of clinical supervi-
sion on patient outcomes. This is a worthy next step for exploration and one that
finds some expression in this book.
At the time of writing this preface there are emerging constraints on health care
funding as the world economies struggle to recover their equilibrium, Health pro-
fessionals will be asked to work harder, to better effect and show demonstrable out-
comes. This agenda can only be properly achieved if health professionals are
properly sustained and supported. Clinical supervision offers a vital platform for this
necessary work.
I am delighted to see that this new Routledge Handbook of Clinical Supervision
addresses most if not all of the matters that I raise here. It is likely to sustain its well
found reputation established in the original Fundamental Themes in Clinical Supervi-
sion, as a book of thoughtful reflection, stimulating ideas and reference. This new
volume is commendable in both its scope and ambition.

Professor Emeritus Tony Butterworth CBE

Chair, Academy of Nursing, Midwifery and Health Visiting Research (UK)
Manchester, England
June 2010

References
Bradshaw T., Butterworth, T. and Mairs, H. (2007), Does work based clinical supervision
during psychosocial education enhance outcomes for mental health nurses and the service
users they work with? Journal of Psychiatric and Mental Health Nursing, 14(1): 4–12.
Butterworth, T. and Faugier, J. (eds) (1992), Clinical Supervision and Mentorship in Nursing,
London: Chapman & Hall.
Butterworth, T., Bell, L., Jackson, C. and Pajnkihar, M. (2008), Wicked spell or magic bullet,
a review of the clinical supervision literature 2001–2007, Nurse Education Today, 28(3):
264–272.
Foreword II
David J. Powell

Much has been written about clinical supervision over the past 30 years, covering
various disciplines and perspectives. Despite this body of research and literature,
there have been gaps in the books published to date, including my own. This book
does an excellent job in filling these gaps and pointing the field in a clear direction
for the future.
First, the field of clinical supervision needs further literature, offering updated
research activity and findings from various settings, disciplines and especially, differ-
ent countries. The majority of the literature on the subject has originated from
Western countries and not surprisingly reflects a Western perspective. As a result,
important questions remain largely unanswered such as: how does one provide clini-
cal supervision in other cultural environments and countries? How does one estab-
lish a system of supervision in a different cultural context? Sue and Sue (2007) in
Counseling the Culturally Diverse write about counselling different cultures. The inter-
national, multi-­disciplinary journal, The Clinical Supervisor, periodically has articles
on supervision in different countries. This new book provides a truly international
perspective on the most contemporary findings from American, British, Canadian,
European, New Zealand and Australian perspectives. If Thomas Friedman (2007) is
correct in his acclaimed book The World is Flat, this new book’s international focus is
consistent with globalisation and the global market place of health care delivery.
Second, most of the literature on clinical supervision in North America is from
an academic perspective, pre-­certified, pre-­practice individuals who are in university
settings. A ‘real-­world’ perspective is vitally needed. This book provides such a per-
spective, reviewing the realities of clinical supervision in acute inpatient settings,
leadership and governance positions, a National Health Service Community Trust
perspective, and a rural health care organisation. The book combines the contribu-
tions of scholars, practitioners, and practice developers based in ten different
countries.
Third, most books in the field come from a single-­discipline perspective: social
work, marriage and family counselling, professional counselling or alcohol and drug
abuse counselling. Although useful, such a focus is too limiting, as health care deliv-
ery systems encompass multiple disciplines and operate as inter-­disciplinary entities.
This book includes contributions across disciplines, including physicians, psycholo-
gists, psychiatric mental health nurses, social workers, palliative care nurses and
generic nurses.
Fourth, although the importance of the supervisory alliance and various
approaches to supervision have been emphasised in the literature, Cutcliffe et al.
xxiv   Foreword II
bring the latest research to bear on how this alliance affects attitudes, skills and
intention of supervisees and supervisors. The book addresses the critical issues of
experiential learning, providing an underpinning theoretical perspective on clinical
supervision, using solution-­focused techniques in clinical supervision, and address-
ing the key issues related to supervisor training and requirements.
This latter point is critical. As health care agencies undergo difficult financial
times and health care reform, justifying the cost of a quality clinical supervision
system to management and administrators of these organisations can be a hard sell.
Why should we spend money on non-­revenue bearing activities, such as training and
clinical supervision? The book addresses this issue by exploring the impact of clini-
cal supervision on job satisfaction, burnout and the quality of care. In an outcome-­
driven health care world, this book shows that the better the clinical supervision, the
better patient retention and the quality of care. If you want to sell a system of clini-
cal supervision to management, that’s a reasonably cogent argument.
Finally, far too much of the literature in the field is retrospective, looking back-
ward at where we’ve been rather than looking to the twenty-­first century and
beyond, the successes, challenges and the road ahead. This book concludes with a
dynamic perspective on the future and the role clinical supervision can play in
shaping that future.
John Cutcliffe, Kristiina Hyrkäs, and John Fowler appropriately point us in the
direction for further writings on subjects such as record keeping, legal issues in clin-
ical supervision, working with special populations (substance abuse), and other
international foci (Asia, Africa and South America – populations from which there
remains a paucity of research and literature). We look forward to these issues and
others being addressed in the future by these and other authors.
John Cutcliffe, Kristiina Hyrkäs, and John Fowler bring outstanding credentials
to this book, including vast international and multi-­disciplinary perspectives. There
are few writings in the field of training and clinical supervision that can offer such a
depth of viewpoint. These are highly credible authors, whose work makes a signific-
ant contribution to the field.
Today, health care delivery offers many benefits and challenges. Clinical supervi-
sion is one of the keys to maintaining and improving the overall quality of care, the
professional development of personnel, and patient and staff retention. This book
makes a significant contribution to the health care field and the study of clinical
supervision. I highly recommend this book to practitioners from all behavioural and
health care disciplines.

David J. Powell
President of the International Center for Health Concerns

References
Friedman, T.L. (2007), The World is Flat, revised edition, London: Penguin.
Sue, D.W. and Sue, D. (2007), Counseling the Culturally Diverse, 5th edn, New York: Wiley &
Sons.
Preface

The editors of this book are delighted that we were asked to produce the Routledge
Handbook of Clinical Supervision and that this provided the opportunity for significantly
expanding, enhancing and updating Fundamental Themes in Clinical Supervision. The jus-
tifications and rationales for writing a book about clinical supervision are just as appli-
cable today as they were when the original book was proposed and subsequently
produced. Furthermore, an examination of the extant literature will show that clinical
supervision as an international and multi-­disciplinary phenomenon may well have
grown during the last decade. Our knowledge base focusing on clinical supervision has
expanded and perhaps more importantly, deepened. Some disciplines which hitherto
have not been associated with clinical supervision have now made (most welcome) sub-
stantive contributions to the body of work. Some countries appear to have moved
forward with their own clinical supervision agenda; others, very interestingly, have not.
As a result, and almost a decade on since Fundamental Themes in Clinical Supervision, it
seemed that the time was right to move towards producing a new book.
This book retains the features which made Fundamental Themes in Clinical Supervi-
sion a well-­reviewed and highly regarded text and we have added material in the
hope that this expands the book’s, to borrow a term from Tolkien’s parlance, ‘appli-
cability’. In addition to reviewing and subsequently updating the material in Funda-
mental Themes in Clinical Supervision, 23 of the 33 are new chapters, many of which
are logical progressions and/or developments from chapters included in Fundamen-
tal Themes in Clinical Supervision. The remaining nine chapters have all been updated
and revised. The editors also believe this format and construction of the book will
help to provide a sense of continuity, with readers being able to follow the evolution
of our knowledge base in certain areas which were covered in Fundamental Themes in
Clinical Supervision and at the same time, being exposed to new issues, new debates,
new developments and new knowledge.
The forewords to this book, generously provided by Professor Tony Butterworth
and Dr David Powell, complement that provided by Sarah Mullally, the then Chief
Nursing Officer for the United Kingdom for Fundamental Themes in Clinical Supervi-
sion. Further, given Professor Butterworth’s joint editorship of Fundamental Themes
in Clinical Supervision, we feel this further contributes to a sense of continuity
between the two books. And given Dr Powell’s international and multi-­disciplinary
efforts to develop clinical supervision, we feel that this underscores the increasing
multi-­disciplinary and international interest in the subject. As with Fundamental
Themes in Clinical Supervision, we welcome feedback, comment and review and hope
that such information might inform the production of a new edition in the future.
xxvi   Preface
This book includes all of the outstanding features that made Fundamental Themes in
Clinical Supervision a success such as:

• Contributions from leading scholars, practitioners and practice developers,

each of whom has an established reputation in the substantive area of clinical
supervision.
• Chapters representing a broad selection of both new and more familiar (exist-
ing) material focused on clinical supervision.
• Considerable breadth – as there are now five discrete yet linked parts in the
book (Fundamental Themes in Clinical Supervision had four).
• Chapters detailing the most contemporary research activity and findings from
various settings, disciplines and countries.
• Contributions from scholars, practitioners and/or practice developers based in
ten different countries, thus providing a genuinely international perspective.
Such genuinely internationally focused texts are also more in keeping with the
increasing shift towards globalisation and the global market place.
• A balance between analytical and descriptive chapters and their associated styles
of writing; with a corresponding increase in the width of appeal of potential
readers.
• Contributions from a range of disciplines which were not included in Fundamen-
tal Themes in Clinical Supervision, making this a genuine expansion and develop-
ment on that earlier book rather than simply updating a few references. These
disciplines include clinical supervision contributions from physicians (general
practitioners), psychologists, psychiatric/mental health nurses, palliative care
nurses, social workers and generic nurses. There is also far more material that
focuses on multi-­disciplinary and interdisciplinary developments.
• The balance that Fundamental Themes in Clinical Supervision had, which should
still make it attractive to students, practitioners, educationalists, and researchers.

In putting together the Routledge Handbook of Clinical Supervision and recognising

and operating within word/space limits, the editors would like to point out that dif-
ficult choices had to be made around which issues/developments to include and
which not to. The editors wish to emphasise that in no way is our contents list meant
to be exhaustive or representative of the only clinical supervision issues that warrant
debate. Understandably, the choice of which chapters to include reflect, at least in
part, the views, values and to some extent, the interest of the editors. The idiosyn-
crasies of the editors notwithstanding, we believe the chapters will have currency
and meaning for the disciplinary groups currently involved (or engaged) in clinical
supervision and for those that are considering this as a future option. The chapters
(and their corresponding issues) have been selected, in part: as a result of our com-
munication with the international clinical supervision academe; as a result of search-
ing the extant literature for ongoing issues/developments/debates; as a result of the
introduction of some health care policy; and, in part, in an attempt to capture prac-
tice, policy, education and research clinical supervision related debates. Accord-
ingly, the chapters might be regarded as a collection of some of the key issues/
developments and challenges associated with the substantive area of clinical supervi-
sion. Additional issues, developments and challenges that we considered featuring
in the book include:
 Preface   xxvii
• power and control in clinical supervision;
• clinical supervision for psychiatrists;
• record keeping in clinical supervision;
• clinical supervision contributions from the Far East, Africa and South America;
• legal issues in clinical supervision;
• clinical supervision in doctorally prepared, clinical psychology programmes;
• doctoral level training in clinical supervision;
• magnet hospitals, criteria and clinical supervision;
• clinical supervision for people working with specific populations, groups and/
or problems e.g. alcohol substance misuse.

It is our hope that these and other issues might form the cadre of a new book some
time in the future.
Finally, it would be remiss of the editors if they did not point out that these chap-
ters do not constitute the definitive position on any of the issues featured. We
acknowledge that debating ongoing issues can (should?) be an iterative process;
positions and opinions change as new evidence emerges, as the dominant discourse
changes and/or as society’s values evolve. The editors hope that this book might be
considered as a contribution that adds to our substantive knowledge base of clinical
supervision and helps advance our clinical supervision-focused practice, education,
policy and research.

John R. Cutcliffe, Kristiina Hyrkäs and John Fowler

December 2009

Stylistic footnote: as with Fundamental Themes in Clinical Supervision, the editors have
highlighted certain selective sentences, passages or parts of sentences by emphasis-
ing these, here, with italics. These selections are not random and to a greater or
lesser extent are bound to reflect the particular nuanced views of the editors.
1 Introduction
Global perspectives on fundamental
themes in clinical supervision
John R. Cutcliffe, Kristiina Hyrkäs and John Fowler

Why another clinical supervision book?

It is now almost ten years since Fundamental Themes in Clinical Supervision (Cutcliffe et
al. 2001), was written and during these years, clinical supervision (CS) has remained
on the radar for those involved in health care practice, education, development
and/or education. While it might be argued that attention to CS within academic
journal articles may have passed beyond its zenith (arguably this occurred during
the 1990s), examination of the extant literature reveals that CS is very much still a
matter of high interest. The possible decline in the number of papers notwithstand-
ing, a closer inspection of the extant literature shows a number of interesting things.
First, the papers that continue to be published appear to add something new, mean-
ingful and/or significant to the literature (and it would be inaccurate to assert this
of the papers produced during the 1990s when there was a great deal of repetition).
Second, while it might be said that some of the earlier published work could have
‘delved a little deeper’ into the substantive issues, the more recent published work
appears to do just that. Third, almost no new CS books have emerged during recent
years.
As with any longitudinal, evolutionary, cumulative approach to knowledge gener-
ation, the existence of earlier work by no means serves to suggest that there is
nothing new worth saying; on the contrary, what this actually means is that we have
more questions now than perhaps we did before (Toulmin 1967; Popper 1972). A
further outcome of interrogating the extant literature is that of the discovery of gaps
in our knowledge base. Accordingly, it is perhaps worthy of note that some existing
questions do not appear to have been fully debated or resolved and others have yet
to be asked. As a result, this book attempts to make a significant (if not seminal)
contribution to the extant CS literature by focusing on issues that continue to be of
contemporary interest and furthermore by focusing on hitherto under-­examined
issues.
In addition to the continued widespread interest in CS, there are additional
reasons for producing a new book.
First, CS is now much more of a genuine global phenomenon than it was ten years ago.
More countries have embraced CS within various practice domains (e.g. see New
Zealand, Australia, Canada); more individuals are thus involved in giving/receiving
CS, studying CS, introducing CS into policies and practices, and teaching/training
CS. The international interest is now far larger than it was ten years ago and yet with
this context in mind, few (if any) books have been produced recently that will have
2   J.R. Cutcliffe et al.
the content, international authorship and thus high utility/applicability that this
book has.
The ongoing need for CS should also be considered with the context of the evidence-­based
practice movement which has swept several nations. Those nations and populations who
are interested or already engaging in CS thus need to have the most comprehensive,
robust empirical evidence upon which to base their practice. This book pulls
together numerous key research themes within CS and provides some of the most
contemporary findings available. Again, these are in no way limited to one country.
Contemporary issues pertaining to litigation and quality of care still abound (and
some would say these have increased during recent years). Mindful of this develop-
ment and the inescapable link between CS and quality of care/clinical governance,
we have included new chapters that specifically focus on these issues. While the ori-
ginal editors touched on this in Fundamental Themes in Clinical Supervision, policy and
quality matters have moved on, therefore a book that includes chapters on links
between CS and these issues is much needed.
Again, with reference to international developments, one of the most compelling
developments in recent years is the rise of the Magnet Recognition Program and
the associated ‘movement’. Perhaps analogous or similar to the Nurse (Practice)
Development movement synonymous with the Kings Fund in the 1980s and some
United Kingdom universities in the 1990s, Magnet Status is a huge deal right now in
the United States. The Magnet Recognition Program was developed to recognise
health care organizations that provide excellence in nursing practice. The new
Magnet Model emphasises today five domains:

1 transformational leadership
2 structural empowerment
3 exemplary professional practice
4 new knowledge, innovations and improvements
5 empirical outcomes.

We will not belabour the obvious parallels with each of these five domains (and the
practices within them) with the nature/rudiments of CS. Bearing in mind that hos-
pitals in the United States are private businesses, many hospitals are aspiring to
achieve Magnet Status and with that, an additional element to their marketing strat-
egy for their organisations. As a result, hospitals in the United States that aspire to
Magnet Status should, we would argue, consider how embracing CS within their
organisation and culture can contribute to their efforts to become (or remain) a
Magnet site.
Finally, it needs to be acknowledged that CS has not only spread across nations but it has
also spread into disciplines which hitherto had very little or no CS activity. Though we high-
lighted these possible developments in Fundamental Themes in Clinical Supervision,
the then possibilities have now become reality to the extent that GPs, palliative care
nurses, primary care nurses and others are now engaged in CS. We have accordingly
captured the state of the art/practice of CS for these groups by including chapters
that specifically focus on these populations. Accordingly, this book not only builds
on the strengths of Fundamental Themes in Clinical Supervision, it not only updates
those still relevant chapters from that book, but it also includes new material to
reflect the genuine international nature and the increasingly multi-­discipline of CS
 Introduction   3
and does so by bringing together a collection of many of the leading international
scholars in this area.
Our experience (and many of the findings detailed in this book) suggest that
when people have had some personal experience of CS, they appreciate it, under-
stand it, become aware of its utility, application and worth, and want it. Con-
sequently, rather than a book that is based on theoretical perspectives, this book
consists of a collection of chapters from authors each of whom are involved in prac-
tice relating to supervision, each of whom have experienced CS; and it has left a
lasting impression. Those chapters on education/training have been written by
authors who provide education/training (and receive CS) themselves. Those chap-
ters on introducing, implementing or developing CS into an organisation, have
been written by authors who have actively engaged in such endeavours (with docu-
mented success it should be noted). Those chapters on practicing/experiencing CS
have been written by authors who, not surprisingly, practice and experience CS first-­
hand and thus have their own lived experiences to draw upon. Those chapters that
feature contemporary research findings are each based on research conducted by
the respective authors. The chapters that catalogue, describe and critique the state
of the science of CS in a variety of different countries are each written by experts
from the countries and regions represented. It should also be noted that these dif-
ferent sections lend themselves (arguably) to a different style of writing; accordingly
some have a more academic sense or ‘flavour’ than others.

The structure of the book

After the first two chapters set the scene (so to speak) and provide some back-
ground and context to CS, Part I of the text is concerned with education, training
and approaches to CS. Consequently, Chapter 3 examines the how and the why of
Brigid Proctor’s Supervision Alliance model, and looks at some of the open learning
methods of training in CS. Chapter 4 makes the case for training/equipping student
practitioners to become competent supervisees rather than supervisors, and suggests
a possible structure for such education/training. Chapter 5 looks at experiential
learning as a theoretical underpinning to CS and includes some pragmatic sugges-
tions as to how one can assess, identify and address issues that sometimes lead to
malfunctioning in CS. Chapter 6 features the development and delivery of a
diploma-­level CS training course at the University of Nottingham. Chapter 7 exam-
ines the hitherto under-­examined matter of training requirements for competent
CS. Chapter 8 focuses on CS through a post-­modernist lens and Chapter 9 offers the
original idea of adopting a solution-­focused approach to CS.
Part II of the text is concerned with the introduction, implementation and devel-
opment of CS into practice, policies and into health care organisations. Therefore,
Chapter 10 examines the relationship between clinical supervision and clinical gov-
ernance and draws them together with a convergence model. Chapter 11 outlines
how a group of practitioners (lead professionals) facilitated the widespread imple-
mentation and development of CS within a National Health Service Community
NHS Trust. Chapter 12 provides a summary of the literature review of CS, ten years
on from the review of CS literature commissioned by the UKCC (now the Nursing
and Midwifery Council). Chapter 13 focuses on a recent effort to introduce CS
within a large National Health Service acute care trust. Chapter 14 presents a
4   J.R. Cutcliffe et al.
number of descriptive accounts of how CS is working in one geographical area in
the United Kingdom, including a number of case studies which provide very differ-
ent pictures of how the essential elements of CS were adapted to the needs of each
specific environment. And Chapter 15 describes an innovative and systematic
approach to introducing CS in a rural health care organisation in Australia.
Part III of the text is concerned with the actual practice and lived experiences of
CS within different health care professions (disciplines) and specialisms. Con-
sequently, Chapter 16 leads with a focus on the experiences of a Community Mental
Health nurse. Chapter 17 looks at CS for nurses working in palliative care settings.
Chapter 18 features the experiences of general practitioners (physicians) in the
United Kingdom who receive and participate in CS. Chapter 19 explores the prac-
tice of cross-­discipline group supervision and Chapter 20 features the cultural realit-
ies of CS in an Australian acute inpatient setting. Chapter 21 concludes this part by
examining CS supervision for nurse educationalists and sets this practice within the
context of a post graduate psychiatric/mental health nursing course.
Part IV is a collection of research reports and empirical studies which constitute
some of the contemporary (and international) research activity that examines
aspects of CS. Accordingly, Chapter 22 draws on recent extensive research from
Scandinavia and in other parts of Europe. Chapter 23 describes an empirical study
which sought to explore relationships between CS, burnout and job satisfaction.
Chapter 24 features a research study that examined the under-­explored issue of
multi-­disciplinary attitudes towards CS in the United Kingdom, whereas Chapter 25
reports on the findings of a qualitative study that used a focus group method to
evaluate the experience of receiving CS. Chapter 26 focuses on research findings
pertaining to CS for those who occupy administrative and leadership positions and
Chapter 27 considers the argument and evidence for using case studies as one
means of producing qualitative evaluative data; and it reports findings from a series
of case studies which produced evidence regarding personal, professional and prac-
tice developments enhancements that ensued as a result of participating in CS.
Part V of the text is concerned with presenting international perspectives on,
and experiences of, CS and seeks to provide the reader with an understanding of
the state of the science regarding CS in these featured countries. Therefore,
Chapter 28 reports on the state of the science of CS in Australia and New Zealand.
Chapter 29 reports on the state of the science of CS in Europe. Chapter 30 shifts
our emphasis across the Atlantic Ocean and reports on the state of the science of
CS in the United States and Chapter 31 on the state of the science of CS in Canada.
Chapter 32 rounds off this part and takes a slightly different slant and offers up
some key comparisons between European and North American conceptualisations
of CS. The book concludes by considering: where do we go from here? Con-
sequently, Chapter 33, on the future of CS, highlights some key issues/debates that
arguably need to be resolved; highlights important policy, practice, education and
research concerns and offers the editors’ view on what could be addressed during
the next decade.

The editors’ position on clinical supervision

As with the editors of Fundamental Themes in Clinical Supervision, the editors of this
new book share the view that there is no one single correct or ‘best’ way to carry out
 Introduction   5
CS. However, any activity is based on certain implicit or explicit assumptions. Rather
than give yet another definition of CS, we want to spell out some of those assump-
tions, of what we think it is or is not in our considered opinion. The contributors to
this book are all talking about the kind of CS that fits within these parameters. In no
particular order of priority, the editors posit that these parameters indicate clinical
supervision is necessarily:

• supportive;
• safe, because of clear, negotiated agreements by all parties with regard to the
extent and limits of confidentiality;
• centred on developing best practice for service users;
• brave, because practitioners are encouraged to talk about the realities of their
practice;
• a chance to talk about difficult areas of work in an environment where the
person attempts to understand;
• an opportunity to ventilate emotion without comeback;
• the opportunity to deal with material and issues that practitioners may have
been carrying for many years (the chance to talk about issues which cannot
easily be talked about elsewhere and which may have been previously
unexplored);
• not to be confused with or amalgamated with managerial supervision;
• not to be confused with or amalgamated with personal therapy/counselling;
• regular;
• protected time;
• offered equally to all practitioners;
• involves a committed relationship (from both parties);
• separate and distinct from preceptorship or mentorship;
• a facilitative relationship;
• challenging;
• an invitation to be self-­monitoring and self-­accountable;
• at times hard work and at others enjoyable;
• involves learning to be reflective and becoming a reflective practitioner;
• an activity that continues throughout one’s working life.

We would argue that, ultimately, CS has to be concerned with benefiting service users
as well as health care practitioners. The truth of the matter is that we are all potential
clients or users of health care. Additionally, each of us has, in some way, paid for such
care and it is entirely understandable that when we are to be recipients of health care,
we would all want the best care possible for ourselves and our significant others. We
posit that this ‘best care possible’ can only be delivered by the front line staff, who are
competent enough and healthy enough. We believe that engaging in CS has the
potential to help bring about precisely that scenario. It can help keep practitioners
become and remain competent and healthy enough to provide this best care possible.
Unless CS ultimately does have an influence on the care provided, it ceases to be what
it was designed to be and becomes something of a rather narcissistic, self-­absorbed
activity for staff or yet another (unwanted) managerial monitoring tool.
There is an increasing requirement for staff who are engaged in helping relation-
ships within health care to be accountable for their actions. However, the mechanisms
6   J.R. Cutcliffe et al.
for encouraging, nurturing and monitoring this accountability remain vague and
somewhat immature in their conceptual development. At the same time there is an
ongoing requirement for such individuals to re-­register as competent practitioners.
Inextricably linked with one’s eligibility for re-­registration is the need to demon-
strate a commitment to continuous and ongoing professional development and, at
the same time, a degree of individual accountability (Cutcliffe and Forster 2010, in
press). In order to operate as a competent, ethical and safe practitioner, one first
needs to be accountable to oneself and then accountable to another. It is the belief
of the editors (and the authors in this book) that CS provides one mechanism
whereby these processes can be achieved.

What should you gain from this book?

Having identified that this book offers the reader something different from other
books on CS, the reader ought to gain something different from reading it. So what
should the reader be able to gain as a result of reading this book?
Perhaps you should first ask yourself: what do I want to know about CS?
Then, if you are interested in becoming a supervisor (or supervisee), you should
turn to Part I, on education, and there you will discover what type of training/edu-
cation is available, what options you can pursue and at what academic level. If you
are interested in implementing/developing CS in practice and/or in your organisa-
tion, you should examine Part II and can then see some options of the ways this can
be brought about, and identify some of the hurdles to the introduction of CS. If you
are interested in the practice of CS you should look to Part III on practice and
become aware of what practice is occurring, how practitioners are experiencing CS
and how it might be of benefit to them. If you are interested in research, then you
should examine Part IV and can then determine what are the next logical questions
to be asked in CS, where the current knowledge base is and where future research
should be focused. And if you are seeking a greater sense of this global phenome-
non that you might logically begin with the final part of this book, on the interna-
tional state of the science.
It is the editors’ opinion that this book identifies some of the real benefits of
receiving CS and this evidence has been obtained from real experiences. The evid-
ence has been provided by practitioners who share the difficulties, constraints and
dilemmas that many hard-­pressed and busy health care practitioners experience.
The writing does not come from a collection of academics who live in world far
from the realities of clinical practice. As a result, the editors view this book as a
‘carrot’ book, rather than another ‘stick’ book. It provides the reader with some
hope, something to encourage them, rather than adding to the already stifling load
of ‘shoulds and oughts’ that practitioners bear. It demonstrates, as a result of the
international chapters, how different countries interpret CS within their national
context(s). It is thus interesting and illuminating to see different perspectives; and
such perspectives might make practitioners, educationalists, managers/administra-
tors, policymakers and researchers think about CS in a different way. It shows that
in the substantive area of CS, there is evidence to suggest that several countries now
occupy an influential potential, and thus there may well be something that we can
all learn from other countries. Finally, it sets CS in context within a multi-­
disciplinary context and reflects that whilst CS may have been available for decades
 Introduction   7
in certain nations, its potential to support staff, to help them become more individu-
ally accountable and to improve client care has not yet been fully realised.
Consequently, the ending of this chapter in Fundamental Themes in Clinical Super-
vision remains as salient and relevant today as it did at the end of the twentieth
century. To borrow an expression that arises from contemporary parlance: CS has
come far, but there is still a long way to go.

References
Cutcliffe, J.R. and Forster, S. (in press), Guest editorial. Professional registration bodies:
international variation in the protection of the public, International Journal of Nursing Studies
(accepted for publication October 2009).
Popper, K.R. (1972), Objective Knowledge: An Evolutionary Approach, Oxford: Clarendon Press.
Toulmin, S.E. (1967), The evolutionary development of natural science, American Scientist,
55(4): 456–471.
2 Clinical supervision
Origins, overviews and rudiments
John Fowler and John R. Cutcliffe

This chapter explores the origins of clinical supervision and proposes reasons why it
was adopted into the profession at that particular time in history, questioning whether
clinical supervision is just another fad that has entered the nursing language and
culture. Undoubtedly the nursing profession is prone to fashions and fads and at times
it is difficult to differentiate what is useful and what is a whim. The chapter then exam-
ines the conceptual overlap of similar terms such as mentoring and preceptorship and
identifies some key features of clinical supervision.
We believe that this is an important chapter for managers, clinicians and educators.
Whatever role we play in the profession it is important to understand the why and how
of our supporting structures. At its worst, clinical supervision has the potential to be a
time-­consuming negative experience but at its best, clinical supervision has the poten-
tial to galvanise and motivate individuals and teams and to be a significant part in the
quality assurance process. So what is it? Where did it come from? And is it here to stay?

Introduction
Many years ago, in the US, Peplau (1927) identified that nurses had a need for clini-
cal supervision. She talked implicitly about reflective practice as part of clinical
supervision, stating that the staff nurse should come prepared with notes or verba-
tim data and that the supervisee should do most of the talking. The aim of the
supervisor was to try to perceive the interactions in the context of the situation and
to suggest alternative modes of responding. There appears little else in the nursing
literature from this time that identifies anything that resembles Peplau’s original
concept of supervision as a formal meeting with a supervisor in which a supervisee
comes with reflective notes and the supervisor’s main role is not to lecture, but to
ask questions and suggest alternative perspectives.
Although the idea of senior nurses directing junior nurses in their clinical work
has been in existence since the days of Florence Nightingale, the practice of clinical
supervision was not formally debated in the UK until the late 1980s. One of the early
formal definitions of clinical supervision appearing in the UK literature was from
the Department of Health in a document entitled A Vision for the Future – The
Nursing, Midwifery and Health Visiting Contribution to Health and Health Care (Depart-
ment of Health 1993). The document was endorsed by the Secretary of State for
Health, the Chief Executive of the National Health Service Executive and the Chief
Nursing Officer. It was an important and influential document. The ‘vision’ con-
 Origins, overviews and rudiments   9
tained within the document drew upon a number of major political, professional
and health policy documents of the time. Twelve key targets were set, the tenth of
which related specifically to clinical supervision, which was defined as

a formal process of professional support and learning which enables individual

practitioners to develop knowledge and competence, assume responsibility for
their own practice and enhance consumer protection and safety of care in
complex clinical situations.
(Department of Health 1993: S.3.27, p. 15)

Professor Bishop, who was lead Nursing Officer at the DOH for clinical supervision
when subsequently writing about the background of clinical supervision (Bishop 1998),
indicates that this high visibility political drive to introduce formal clinical supervision
into the nursing profession was driven by ‘a number of concerns about supervision and
support of safe, accountable practice’ Bishop 1998: 1), this concern being fuelled by a high
profile inquiry into the unlawful killing of a number of children by the nurse Beverly
Allitt (Clothier Report: Department of Health 1994). (Professor Bishop has contributed a
chapter for this book examining clinical supervision and clinical governance – see Chapter 10.)
Bishop states that it was no coincidence that on the day that the Clothier Report was
published there was also a Department of Health commissioned paper distributed to
the NHS and professional bodies on clinical supervision (Faugier and Butterworth
1993). Bishop points out that although this may appear to be a political ‘sop for bad
publicity’ it was actually a genuine move from within the nursing profession to support
the development of high quality care. Anecdotally it has been suggested that senior
nurses of that time used the political momentum generated from the negative public-
ity relating to the Beverly Allitt inquiry to move the concept of clinical supervision from
the professional nursing agenda to the central government’s policymaking agenda.
So why did clinical supervision become such an important topic in the early 1990s? Why
did it attract such strong professional and political backing at that specific time in the develop-
ment of the nursing profession?
Undoubtedly the move from the professional agenda to the political one was
strongly facilitated by the national publicity of the Allitt inquiry as described above.
But why was clinical supervision already on the professional agenda at a national
level and why was it welcomed by clinical nurses at all levels of the profession? There
are a number of factors which seem relevant to this question:

1 In the middle of the 1970s nursing began moving away from a task-­orientated
system of care to one where patients’ care was planned and delivered in a ‘holis-
tic’ way, ‘the nursing process’, with one nurse assessing, planning and delivering
the care for a small group of patients. This reinforced the role of the nurse as
an increasingly individual practitioner in their own right. Previously the custom
in task-­orientated care had been for the senior nurse, the ‘ward sister’, to list
the care for each patient, often in a routine way. She then grouped the tasks for
all the patients and then allocated the tasks to one of the staff in the team. e.g.
the staff nurse would give out medication, the junior nurse would empty bed
pans and keep the sluice clean, the less junior nurse would wash patients etc.
with each group of tasks being allocated to a person with the appropriate skill
level. Towards the end of each shift the ward sister would do her rounds of the
10   J. Fowler and J.R. Cutcliffe
patients and inspect the various tasks that had been performed. Thus there pre-
viously existed a system whereby a senior and experienced nurse assessed her
patients, planned their care, allocated different aspects of that care to appropri-
ately trained personnel and then monitored their performance. In terms of
nursing care this was an efficient ‘factory line’ production that had quality assur-
ance built in. Built into this way of working was the apprenticeship model of
training and support. As the junior nurse mastered the bed pans and sluice,
they then progressed to washing patients and then to doing simple dressings,
etc. Central to both task-­orientated care and the apprenticeship system was the
ward sister, not uncommonly caricatured as a ‘motherly dragon’. As both these
systems evolved into individualised care and an educational philosophy replaced
the apprenticeship one, then the underpinning supervision and quality assur-
ance provided by the hierarchical structures began to weaken and become lost.
2 Accountability began to move from the hierarchical structures embodied in the
ward sister and medical consultant to the individual nurse. This was demon-
strated by the development in the UK of the Code of Professional Conduct (UKCC
1992) which made individual nurses accountable for their own actions.
3 At the same time as these organisational and philosophical nursing approaches
were changing, cost effectiveness, and efficiency savings became prominent
topics on the health care agendas. Additionally, the nurses working week gradu-
ally reduced from 48 hours to 37.5 to fit in with national trends and European
working regulations. The effects of this are typified by the loss of the handover
period. The handover period was the overlap of the morning shift with the
afternoon shift and the afternoon shift with the night shift. It was not uncom-
mon for the shift patterns to resemble the following: morning shift 7 am–4 pm,
the afternoon shift 12 noon–9 pm and the night shift 8 pm–8 am. Typically the
afternoon saw a four hour overlap between morning and afternoon shifts. This
allowed for staff to have a lunch break and also gave two or three hours during
which training, support and supervision took place. The senior nurse would
teach the less senior one dressings, drug actions etc. Many of the elements now
recognised as clinical supervision occurred during these overlap periods. With
the drive for cost efficiency combined with the reduction of the working week,
these overlap periods were seen as a waste of resources. Shift patterns gradually
changed reducing the overlap periods resulting in a 15 minute overlap in most
clinical areas. Thus traditional organisational systems of support, development and
supervision were fast disappearing from the established working patterns for most nurses.
4 The 1980s also saw nursing developing as an independent profession in its own
right. Individual nurses were taking on far more specialist and independent
roles. This culminated in 2006 (NMC 2006a) with suitably qualified nurses
being eligible to become independent prescribers in the UK.
5 The final significant factor in the health care system at this time was the vast
development in medicine with far more invasive treatments. Patients were
undergoing intensive treatments and chemotherapy; life-­saving operations and
subsequent intensive care nursing become common place. Patients on the wards
were far more acutely ill, but were in hospital for much shorter times. The days
of recovering patients taking the tea trolley around the ward were long gone.
Thus the work of the nurse was becoming far more intense, patients were far
more ill and the turnover of patients much greater.
 Origins, overviews and rudiments   11
The effects of these social, political, health and professional developments in the
mid-­1970s through to the late 1980s resulted in the gradual erosion of well estab-
lished support and supervision structures coupled with the increase in the severity
of patients’ conditions and volume and intensity of work. Additionally accountabil-
ity at an individual level became established within the profession. By the late 1980s
senior nurses were recognising the role of the nurse had changed and was continu-
ing to change. However, the traditional support and supervision structures were no
longer in existence or appropriate for the developing role. Thus a formalised struc-
ture of support and supervision which gave assurance of customer protection began
to appear as a clinical need on the agenda of a number of senior nurses in the pro-
fession. The concept of clinical supervision was born.

Supervision as an umbrella term

There are a number of terms used in the nursing language that have aspects of
supervision as part of their core concept. The terms mentorship, preceptorship and
clinical supervision and reflective practice are used in the everyday language of the
clinical nurse (Burnard 1990; Maggs 1994; Fowler 2005). Some people appear to
use them interchangeably, acknowledging that there probably is a difference
between the various terms, but not being sure quite what that difference is. Core to

Mentor

Clinical Reflective
Supervision
supervision practice

Preceptor

Figure 2.1 Four common terms found in the nursing literature and their relationship to/with
clinical supervision.
12   J. Fowler and J.R. Cutcliffe
most of these terms is the concept of supervision. Barber and Norman (1987) pro-
vided one of the earlier definitions of supervision within the nursing profession as:
“an interpersonal process where a skilled practitioner helps a less skilled or experienced practi-
tioner to achieve professional abilities appropriate to his role. At the same time they are offered
counsel and support”. There are four terms that have appeared in the nursing literat-
ure and culture that fulfil in some way this initial definition of supervision and have
a relationship to or with it. These are:

• preceptorship
• mentoring
• reflective practice
• clinical supervision.

Preceptorship
Peutz (1985) differentiates preceptorship from mentoring in that it has a more
active teaching and supervision role, and this general differentiation between men-
toring and preceptorship is true across continents. However even the term precep-
torship has different interpretations in the US and UK. In America the term is used
to describe the support, teaching and direction that student nurses receive while on
clinical placement. Thus in the US preceptorship includes: teaching (Williams et al.
1993), learning contracts (Andrusyszyn and Maltby 1993), developing clinical com-
petence and confidence (Myrick and Barrett 1994) and clinical socialisation
(Ouellet 1993; Dibert and Goldenberg 1995). In addition, it is used to describe a
general orientation and teaching programme for new or junior staff (Dibert and
Goldenberg 1995; Dusmohamed and Guscott 1998).
In the UK the term preceptorship was formally introduced into the nursing lan-
guage in 1990. Its specific use arose from the United Kingdom Central Council for
Nursing, Midwifery and Health Visiting (UKCC) post-­registration education and
practice project (PREP) (UKCC 1990). Recommendations 1 and 2 stated that:

There should be a period of support for all newly registered practitioners to

consolidate the competencies or learning outcomes achieved at registration
(4.4). A preceptor should provide the support for each newly registered practi-
tioner (4.10).

This was later developed (UKCC 1993) to include those moving to new clinical
areas, and the preceptorship programme should be a minimum of four months.
More recently the NMC (2006) has revised The PREP Handbook and overt reference
to the term preceptorship has been removed. The PREP Handbook (NMC 2006) now
defines the requirements for periodic re-­registration. However the NMC have main-
tained their commitment to the original concept of preceptorship and this is noted
in one of their A–Z advice sheets – Preceptorship (NMC 2006c, NMC 2006d).
Preceptorship for newly qualified staff has been introduced within nursing in a
fairly consistent in the UK (Ashton and Richardson 1992; Gately 1992; Brennan 1993;
Burke 1994; Skyte 1997, Fowler 2005). It is a short-­lived programme (Burke 1994),
with the focus on the acquisition of knowledge and skills designed specifically to
enable the newly registered nurse to work safely and effectively in a new environment.
 Origins, overviews and rudiments   13
There is an emphasis on assessing this nurse’s individual needs (Ashton and Richard-
son 1992), with instruction and support, rather than emphasising a one-­to-one rela-
tionship common to the mentor literature (Brennan 1993). Once the period of
preceptorship has finished the registered nurse is subject to whatever staff develop-
ment and support processes are available in their place of employment.

Mentoring
Mentoring is a frequently used term both within and outside nursing. It is often
used in everyday nursing conversation but appears to mean different things to dif-
ferent people. As with the term preceptorship, mentoring has different interpreta-
tions in the US and in the UK:

Finding a definition of mentorship is not difficult. The problem lies in selecting

one from the many available and widely contrasting definitions.
(Earnshaw 1995: 274)

Many of the reviews of mentoring within the nursing profession make reference to
the historical derivation of the term ‘mentor’ from Homer’s Odyssey, in which
Odysseus entrusts the upbringing of his son Telemachus to his trusted advisor and
friend Mentor (Donovan 1990; Earnshaw 1995). This model has been adopted quite
widely by the general business world as a relationship in which a more experienced
person nurtures a junior person as they either enter a job or take on a new role
(May 1982; Hagerty 1986). The use of mentoring has also become increasingly
common in schools where it tends to be called a ‘buddy system’ when using senior
students to support and orientate new students or ‘mentoring’ if adults from outside
the school are paired with students who have specific needs.
American nurses tend to see mentoring in a fairly traditional way as a relatively
long-­term relationship between an experienced practitioner and a protégé (Peutz
1985). Darling’s (1984) work from the US on mentoring identifies three main
aspects of the mentoring role. Firstly one who ‘inspires’ the mentee with a ‘vision’
of what to aim for, secondly as an ‘investor’, someone who believes in the mentee
and communicates that belief, and finally as ‘supporter’, the mentor providing
encouragement and reassurance, thus developing confidence.
In the UK, mentoring within nursing has two usages. As with the American inter-
pretation it has a general meaning within management circles of a relationship
between an experienced person and a protégé. This tends to be an informal and ad
hoc relationship seen mainly in the more senior management levels of nursing
(Burnard 1990; Maggs 1994; Butterworth 1998). Here, the term is not well defined
and tends to have a wide usage. It ranges from a committed and intense relation-
ship, focusing on personal and professional development of the mentee, to a more
general and ad hoc meeting.
The second and more formal use of the term mentor within the UK is now well
established as the relationship between the qualified nurse who oversees a student
nurse whilst on placement. The assessment of student nursing competence and pro-
ficiency must be completed by a mentor who is a first-­level registered nurse who has
undergone further preparation to fulfil the role of mentor, this includes teaching,
supporting and acting as the formal assessor.
14   J. Fowler and J.R. Cutcliffe
Originally the English National Board (ENB) (1989) who then regulated nurse
education in England, gave the role of mentor prominence by stipulating that each
student nurse should have a mentor throughout the clinical placements of their
training (ENB 1989, 1993). It defined this as someone who would, by example, facil-
itate, guide and support the learner in the development of new skills, new behav-
iours and new attitudes. There was a separate and more experienced person who
undertook the assessing of students (ENB 1993). Later, the ENB altered the focus
regarding the supervision of students. They combined the assessor and mentor roles
into one mentor role, which was to take on the full responsibility for the teaching,
assessing and support of the student (ENB/DoH 2001). In 2002 the ENB ceased to
exist and the Nursing and Midwifery Council (NMC) took over the responsibility for
setting training and assessment standards. However, the role and function of the
mentor as supervisor and assessor has remained central for student supervision
standards (NMC 2002).
The NMC (2008) currently defines a mentor as

a registrant who, following successful completion of an NMC approved mentor

preparation programme, has achieved the knowledge, skills and competence
required.
(NMC 2008)

The NMC also introduced the term ‘sign off mentor’ as a role in assessment of pre-­
registration nursing for students who are on final placements or for post-­registration
students who are on specialist practice programmes leading to a registrable or
recordable award (NMC 2008). For most nurse training curricula, the mentor is a
clinically-­based nurse, who oversees the student for the time that they are learning
in their clinical area, normally 4–12 weeks. This means that the student will have a
number of different mentors throughout their pre-­registration period – one for
each clinical placement and 10–15 throughout their three years of preparation.
There are only rare examples where the same mentor is attached to a pre-­
registration student for all or most of their training (Morris et al. 1988).

Reflective practice
Reflection underpins much of the practice of preceptorship, mentoring and clinical
supervision. The work on reflection by Argyris and Schön (1974) has influenced a
number of practice-­based professions. Schön (1987, 1991) identifies two types of
reflection: reflection-­on-action and reflection-­in-action. Reflection-­on-action, as the
title suggests, occurs after the experience has occurred and can be recognised in
nurse education settings and in clinical supervision (McCaugherty 1991, Fowler
2006); with the mentor or supervisor being a key figure in helping the student to
reflect on practice. Reflection-­in-action occurs while the practice is being under-
taken and, according to Schön, has the potential to directly influence decisions and
practice outcomes.
The general move to develop a more questioning profession was being articu-
lated to some extent by the emphasis on reflection on practice. Most reviews of
reflective practice acknowledge the stages of reflection (e.g. Mezirow 1981; Schön
1991; Johns 1993; Fowler 2006) and the difficulty of undertaking reflection in isola-
 Origins, overviews and rudiments   15
tion (Johns 1993). Reflective practice was welcomed within the nursing profession
(Snowball et al. 1994; Marrow et al. 1997; Johns 1997) as a way to integrate theory
and practice.
Atkins and Murphy (1993) state that reflection must involve the self and must
lead to a changed perspective. This is echoed by Snowball et al. (1994: 1235):

It is clear in the literature that the involvement of self is a crucial element of the
reflective process.

Atkins and Murphy (1993) state that for reflection to occur the individual needs to
be minimally defensive and be willing to work in collaboration with others. While
this openness and willingness to ‘expose the self ’ is appropriate for some staff, it is
an exercise that many people find difficult to accomplish without guidance from a
skilled person. The clinical supervision relationship offered an opportunity for
reflection on clinical practice under the guidance of a more experienced clinician.
In this relationship the practice of reflection and the role of clinical supervision
come together. Prior to the early 1990s, implementation of reflective practice had been pre-
dominantly with student nurses. It was seen as a valuable tool by others, but required a struc-
ture that was not present in any systematic way within the general nursing profession. Clinical
supervision offered an infrastructure for reflection-­on-practice for all registered nursing staff.

Clinical supervision
As discussed in the early part of this chapter, in 1993, the Department of Health
NHS Management Executive (DOH 1993) published a strategic document, A Vision
for the Future. It was the first time that the term clinical supervision had been used in
a way that implied the introduction of a systematic structure. The document (para-
graph 3.27) described clinical supervision in broad terms that included: develop-
ment, individual responsibility, consumer protection, self-­assessment and reflection.
This has been supported by the NMC whose most recent guidance is in the form of
an information sheet (NMC 2006b) with the aims of clinical supervision as:

• identify solutions to problems;

• increase understanding of professional issues;
• improve standards of patient care;
• further develop their skills and knowledge;
• enhance their understanding of their own practice.

Models of supervision
In the early 1990s, the number of accounts describing how clinical supervision could
work proliferated in the literature. Different models of clinical supervision began to
emerge. At the more humanistic end of the spectrum, Faugier (1992) described a
growth and support model. Initially this emphasises the relationship between the
individuals, then, using the interactions within the relationship, it focuses on
the role of the supervisor to facilitate both educational and personal growth for the
supervisee. This relationship must also, according to Faugier, provide support for
the developing clinical autonomy of the supervisee. Faugier describes many of the
16   J. Fowler and J.R. Cutcliffe
humanistic qualities associated with such growth and support, e.g. generosity, open-
ness, humanity, sensitivity and trust. Chambers and Long (1995) identify a similar
facilitative model of growth and support based on the relationship between the
supervisor and supervisee. These approaches have their roots in a humanistic school
of counselling (Farrington 1995), with its focus on self-­awareness and personal
growth.
From a more behaviourist perspective, Nicklin (1995) argued that tangible out-
comes are required from clinical supervision. He proposed that clinical supervision
should analyse issues and problems, clarify goals and identify ‘strategies for goal
attainment and establish an appropriate plan of action’. The focus was on the out-
comes rather than the process. Nicklin (1997) developed these ideas into a six-­stage
process of supervision. It includes practice analysis, problem identification,
objective-­setting, planning, implementation action and evaluation. Nicklin (1995)
states that the process of clinical supervision should complement other managerial
processes and that clinical supervision should not develop as a vehicle for diluting
or fragmenting managerial responsibility. This ‘outcome’ approach, with its focus
on problem identification and problem-­solving, has its roots in a behavioural school
of psychology (Farrington 1995).

Principles of clinical supervision

People’s experiences of clinical supervision vary widely. Three principles, however,
appear to be core (Fowler 1996):

1 At least two people meeting together for the purpose of clinical supervision.
2 Reflection is used to focus upon clinical practice.
3 Meetings are structured and organised.

A short article by Proctor (1986) writing about youth work, identified three com-
ponents of supervision as: normative (standard setting), formative (development)
and restorative (support). These were quickly adopted by the nursing profession as
key elements in the clinical supervision literature (Bishop 1998).
These three components have stood the test of time with the purpose and func-
tion of clinical supervision encompassing one or a combination of the following:

• a learning process
• a supportive process
• a monitoring process.

The literature on clinical supervision in nursing is quite vast, most of it written in

the last 20 years. A simple ‘Google’ search on ‘clinical supervision in nursing’ reveals
548,000 hits. If you spent two minutes reading each paper, it would take you over
two years to read everything and that would be two years without sleep, nutrition or
anything else. The rest of this book draws upon some of the most noted authors and
authorities on clinical supervision and attempts to condense those two years of
reading for you, into this one authoritative text.
Another Random Scribd Document
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that something had gone wrong in business or that Mr. Dolby was
meditating some coup in business when he forgot to listen to her,
left off talking to her, and walked up and down her pretty drawing-
room, touching the chairs and tables unconsciously as he passed
them with his finger tips, as she remembered having heard some
one say Dr. Johnson used to touch the posts in Fleet-street.

Miss Montressor would have been seriously annoyed, however, if

Mr. Dolby had gone off into one of his fits of absence on the present
occasion. Her own business was in the wind now, and she
considered it worthy of his undivided attention. He did not try her
patience on this point; he listened with genuine interest, which
received a quite perceptible stimulus when Miss Montressor
mentioned that all the arrangements and preparations were being
greatly assisted and facilitated by her American friend, Mr. Foster.

'Foster!' said Mr. Dolby, stooping to pick up his paper-knife; 'the

New York man, I suppose?'

'Yes, I think so; a very pleasant agreeable man, and very fond of
theatricals. He saw Bryan Duval years ago in New York, and called
on him as soon as he came to London. He gave me a delightful
sketch of the reception we are certain to meet with, and has
promised us private introductions to no end.'

'Foster I' repeated Mr. Dolby, in a pondering tone. 'I don't think I
know any one of the name--it is not common among us. What sort
of looking man is he?'

'Decidedly good-looking--more like an Englishman than an

American, I fancy, according to our notions of what you call the
"American type."'

Mr. Dolby laughed. 'Don't talk stuff about the American type, my
child; there is no such thing. There are scores of types among us,
the most cosmopolitan and practical nation in the world. I now
remember exactly what you mean by Mr. Foster's being more like an
Englishman than an American. You mean that he looks healthy,
cheery, and as if neither his sleep nor his digestion was ever
troubled by overwork and anxiety. This is one of the favourite
delusions of superficial writers and random talkers. Nothing has
struck me, since I have been in London, more forcibly than the
absence of the so-called English type among Englishmen. The rosy
complexions, the stalwart forms, the unembarrassed open
countenances, are just as scarce in London city as in New York;
everybody looks anxious, it seems to me, and most people look
tired. What is Foster?'

He asked the question with a strange suddenness. One would

have thought by his manner he had forgotten Miss Montressor's
mention of her friend in the discussion of the abstract question; but
he had not.

'What is he? I don't know; I did not hear; but I presume he is over
here on business of some kind. O, yes, by the bye, he must be, for
Bryan Duval told me Mr. Foster had come against his will, and wants
to get back. That doesn't look like pleasure, does it?'

'Not particularly. However, Mr. Foster is no concern of mine, only

your meeting any New York man reminds me to impress upon you
that you must not talk about me. Are you attending to me, Clara?'

'O, yes, I am attending to you; and I am sure you need not be

afraid of my telling anything you don't want to have known. I have
kept you dark everywhere, and it is rather dull, I can tell you.'

'Rather dull, is it?' said Mr. Dolby, with a smile. 'You would like a
little more dash about our cosy little arrangements, wouldn't you?
You would like me to do the dinner-at-Richmond and drag-to-races
business. Mr. Foster has been putting that into your head. No, no,
my dear, that is not my line at all; and you must take me as I am,
you know. You are going to star it besides, and you will have plenty
of fun and frolic when away from me; and I am all alone by myself
in this big place.'

Miss Montressor gave her head a toss, half disdainful, half

incredulous. She remembered the ease with which Mr. Dolby had
made her acquaintance, and she believed in his constancy as little as
she valued it.

'I shall not inquire too minutely into your sources of consolation,'
she said; 'and if I were discontented with the present state of things,
you may be quite certain that I should let you know it. It is only
men's wives, remember, who have to put up with the style of life
they don't like, because their husbands do like it; as for us, Vive la
liberté!'

'By all means,' said Mr. Dolby. 'I echo the sentiment which you
have declaimed so prettily.'

She had advanced her right foot, tossed her arm over her
upreared head, and made believe to wave a flag with a gesture full
of spirit. She often produced effects in private life of which her stage
performances fell very far short.

'And since you have mentioned dinners at Richmond,' said Miss

Montressor, with characteristic inconsequence, 'I may as well tell you
at first as last that I am going to dine at Richmond with Duval and
the whole lot. It is Mr. Foster's dinner, and he has sent me an invite
through Duval, so I said I should be delighted. Duval drives me
down--he is to call for me at four.'

She spoke with considerable volubility, which Mr. Dolby correctly

interpreted.

'All right,' he replied; 'have we not just agreed Vive la liberté?- and
especially the liberté which brings such pleasant things in its train by
its prolonged life. I am particularly grateful to my hospitable
compatriot with a taste for theatricals, for I am obliged to go to
Brighton to-morrow, and I shall not get back until Monday morning.'

'I was just about to tell you I should not see you again till then, so
it all happens most conveniently. He doesn't like it a bit,' thought
Miss Montressor, 'but he carries it off pretty well--rather a clever
invention, that Brighton business; but it doesn't impose on me.' She
remarked aloud simultaneously, with great good humour, 'This is
really fortunate, as it turns out; but you might have come, you
know, if you hadn't any objection to meeting Mr. Foster--Bryan Duval
would have got an invite for you directly.'

'Thanks,' said Mr. Dolby, with perfect gravity; 'such a kindness

would have been invaluable under other circumstances; but, as you
have just said, I have no fancy for meeting Mr. Foster.'

'That is lucky,' thought Miss Montressor, as Mr. Dolby bade her

adieu, 'for I have.'

CHAPTER IX.

A DINNER OF CELEBRITIES.

Mr. Duval, punctual to his appointment, pulled up the spanking

chestnuts on to their haunches at Miss Montressor's door exactly at
four o'clock on Sunday afternoon. They were very spanking
chestnuts indeed, and the mail-phaeton glistened with varnish, and
on every- place on the harness where it was possible massive pieces
of silver-plate had been put. All this was, of course, exaggerated and
outré, and quite foreign to Bryan Duval's good taste; but that good
taste had been swamped by a long connection with theatricals, and
the wondering stares of the public, which he would formerly have
shrunk from, he now took delight in, and disdained no method by
which they might be attracted.

The phaeton, the horses, and the harness; the huge bearskin rug,
with the French viscount's coronet, in red, elaborately displayed in
one corner of it, which enwrapped his legs; the very costume of Mr.
Duval himself, far more French than English, in its curly-brimmed
hat, its brilliant necktie, its small jean boots with glittering tips, and
its faultless peau de Suède gloves--all these were merely so many
component parts of the general advertisement.

When people stopped in the street and nudged each other,

muttering, as he could plainly see by the motion of their lips, 'That's
Bryan Duval!' the actor-author inwardly winked, chuckling at the
notoriety, and recognising the success of the performance--inwardly
only, for he knew what a mistake it would have been to do away
with the mysterious interest with which he was regarded by
dropping into the comedian or buffoon, and therefore, when any
public eye was on him, his face preserved the look of suffering
earnestness which it was accustomed to wear on the stage.

When the garden-gate was opened, at the ring of the very

elaborate groom who had slid himself into the road before the
horses stopped, Miss Montressor appeared at the inner door of the
villa; and very pretty and picturesque she looked in her velvet skirt,
and her upper dress of fine gray cloth velvet, bound and buttoned,
and her small chic bonnet to match.

'How good of you to be so punctual!' she said, with a bright smile.

'And how noble of you to be ready at the appointed time!' he

cried, from the phaeton. 'I will give you two extra sobs in your next
tragic part as a reward.'
 'You are a horror,' she said, shaking her handsome parasol at him,
'to speak of your own genius in that way--won't you come in?'

'No, thanks,' said Bryan, with a smile, which was so peculiar that
Miss Montressor flushed slightly, and said in reply:

'There is no one here.'

'O, I don't mean that,' said Duval; 'and I should not have minded
in the least if there had been; but we may as well take advantage of
the brightness of the day, and have a stroll in Richmond-park before
dinner.'

'O, that will be delightful!' said Miss Montressor. 'I am perfectly

ready to start at once. Justine, have I got everything?'

Justine, who was really Jane Clark, but who had adopted her
present appellation from the name of a soubrette in a melodrama,
replied in the affirmative, and Miss Montressor having taken her
place by Bryan's side, they drove away.

The wind was cool, but there was a bright sun, and the road was
enlivened with crowds of people making the most of this, the first
day of anything like fine weather, to escape from the dark streets to
which they had been so long confined. They were off to the river-
side public-houses of Putney and Mortlake, where they would talk
over the details of the race between Oxford and Cambridge, which
had recently been decided, or to the gardens of Kew, where they
would pant in the tropical houses, and examine with intense interest
the prospects of the budding trees and shrubs. They were pleasure-
going people for the most part, who were accustomed to rank the
theatre as one of their chief amusements, and who, from their hard
benches in the pit, made a point of seeing any play which had a
successful run at least once. So that Bryan Duval was well known by
sight to most of them, as well as to the omnibus drivers, who would
lean back, and roar in a hoarse voice behind their wash-leather
gloves to the conductor: 'Know him? Dooval, the hactor!'
 It is not to be supposed that Mr. Duval was unmindful of the
sensation he caused. When the omnibus men touched their hats to
him, he raised his own with a grave graceful bow; but even when he
spoke to his companion he still preserved the same impressive look
upon his face.

'You see, Clara, my dear,' he said, with easy familiarity, though his
lips never relaxed one whit, 'you see how very effective this is.
People often ask me why I keep a mail-phaeton, and a brougham,
and these chestnuts, and all the rest of it; they wonder I don't go
about in a hansom cab; they say I should be much more
independent, and it would be so much cheaper; but independently
of the fact that I prefer my own handsome phaeton and comfortable
brougham to any hansom cab, I find that the expense of them is
almost met by the purposes they serve as an advertisement. Now
this drive to-day is worth to me considerably more than a half
column over the clock in the Times. These people would glance at
that--they wouldn't read it; they never do read long advertisements--
and forget all about it the next minute; but when they go home to-
night, they will say to the children who are sitting up for them, or to
the old man for whom it was too long a walk, "Who do you think we
saw to-day? Why, Dooval, the performer--him that makes love so
well--and driving such a swell trap!" and then one or the other of
them will say they haven't seen me on the stage for some time, and
wonder what I am doing, or what new piece I have written; and
then they will look out the advertisement in the weekly paper, and
you may take your oath that the money for a couple of hundred pit
seats is as good as in my pocket at present.'

As they turned into Richmond-park they saw approaching them,

by another road, a well-appointed drag, with four splendid roan
horses, and driven by a tall gentlemanly-looking man, with a
wonderfully woe-be-gone countenance. On the box beside him sat
an over-dressed young person with blonde hair, and a face that was
blue in the sun and streaky in the shade. She was talking volubly to
her companion, but none of her sallies seemed to have the slightest
effect in rousing him.

'That's Laxington,' said Duval, as the two vehicles neared each

other, 'and Patty Calvert by his side, of course. You know Laxington,
don't you? Ah, then don't be surprised if the bow which he gives you
is a very cool one; it is as much as his life is worth to take notice of
any other woman when the fair Patty is by him. He is too much of a
gentleman not to be courteous to everybody, but my idea is, that he
has a very bad time of it. And now just look at those fellows on the
top of the drag. Two or three of them can trace their descent back to
the Conqueror--though they would have no pull over me there; there
is no better blood than that of the Duvals in all France, my dear
Clara, though that, perhaps, does not interest you--and the rest are
the sons of fellows who have made their money by brewing, or
mining, or carrying goods by railway, or some other gentlemanly
occupation of the same kind, and yet there is not a ghost of an idea
among the whole lot! I assure you, beyond telling a broad story and
retailing the gossip of the backstairs, they have not a word to say for
themselves. Dining in their company is the hardest work I know--
harder even than it must be for you to listen to the odoriferous
protestations of Mr. Hedger's Romeo.'

'I can fancy it,' she said, 'from my little experience in that line.
But,' she added, looking saucily up at him, 'what do you do it for? I
am always seeing your name in the papers as dining with swells--if
you dislike it so, why do you do it?'

'As a matter of business, my dear,' said he, bending down, and

speaking to her quietly, 'because the Duvals lost all their property in
the first revolution, and because the beautiful estate of
Knochnabocklish, County Tipperary, which belonged to my mother's
family, was long since sold in the Encumbered Estates Court;
because I have my own way to fight in the world, and to do that, I
must take whatever weapon comes ready to my hand. Do you
imagine that I like going to these dinners? Do you think I don't know
the terms on which I am received--as a superior Jack Pudding, a
table buffoon, a breaker of that dead dull silence, which without me,
or some one equivalent to me, would reign unrelieved throughout
the whole dreary banquet? By Jove, when the thought comes over
me sometimes, I am ready to start up and rush out of the place, I
am so ashamed of myself for having descended to such depths;' and
Mr. Duval sent his whip curling over the beads of the chestnuts,
causing them to plunge and dart off into a mad gallop.

Miss Montressor neither felt nor showed the smallest fear. Had
Lord Laxington or any of his friends been her charioteer on the
occasion, she might possibly have speedily arranged an impromptu
little scene; but she knew that any such device would be thrown
away upon Bryan Duval, so she merely said:

'How a burst of passion suits you! You look remarkably well when
you are in a rage.'

'Thanks, generous stranger,' said Bryan, conscious that the deer

were his sole audience, and therefore permitting himself to lapse
into a grin. 'It is ages since I have let out in that way, and it will be
ages before I do so again. Thank Heaven, we shall have none of
that sort to-day. Foster left the invitations in my hands, and I think I
have got together rather a good party.'

As he spoke, they drew up to the door of the Star and Garter.

Patricians as well as plebeians had taken advantage of the
brightness of the day; there was a goodly show of drags and private
carriages, from which the horses had been removed, and the hall
was filled with persons who had either just arrived, or who were
waiting for other members of their party. The groom was moving
slowly off with the spanking chestnuts, and Bryan Duval, with Miss
Montressor on his arm, was just ascending the steps, when a
gentleman, separating himself from a knot of persons with whom he
had been in conversation, advanced towards him--a man about the
middle height, and a little under middle age, with a thick dark
moustache and frank honest eyes.

'What, Foster, arrived already?' cried Bryan Duval. 'This is

delightful. You know Miss Montressor, I believe?'

'Miss Montressor's reputation was familiar to me before I left my

own country,' said Mr. Foster, raising his hat, 'and I have had the
pleasure of becoming personally acquainted with her since my arrival
here.'

'Very prettily said, Foster,' said Bryan Duval, as they shook hands.
'We came down early, in order that we might have a stroll in the
park before dinner, and get an appetite for all your good things.'

'That's just what I proposed myself,' said Mr. Foster. 'I was naming
it to our friends when you drew up. Let's join them, and all go
together.'

They passed through the house into the garden, where some ten
or a dozen people were gathered together on the lawn. There, in a
loose brown overcoat, with heavy fur collar and cuffs, bell-crowned
hat, fashionably-cut trousers, and patent-leather boots, was
Pierrefonds, the celebrated dramatist, the man who had first
introduced burlesques to the English stage--not the music-hall and
breakdown ribaldry of the present day, but a combination of polished
verse, of Attic wit, and French allusion which, some years ago, had
made the fortunes of the Parthenon Theatre, and mainly helped to
establish the great reputation of Madame Vaurien, its directress.
Pierrefonds's bodily strength is not so great as in those days; his
back is a little bowed, and his walk is somewhat shaky; but he is as
quick-brained in his work, and as clever at tongue fence, as when
the public thronged the pit to roar at his puns, and the brightest
spirits of the day gathered in the green-room to revel in his repartee.

The heavily-built, heavy-browed man in the dark-red beard,

dressed in a suit of dark gray, with his hands in villanous mauve-
coloured gloves, clasped behind his back, is Bob Spate, whose
sparkling little comedies have in the last few years made the fortune
of the little Imperial Theatre, and who is, perhaps, at the present
time the most popular dramatist in England. He is a sad man,
sparing of his speech and more sparing of his smile, giving one the
idea either of being fond of solitude, or unaccustomed to and
uncomfortable in the style of company in which he found himself.
People who did not know his story wondered at such a successful
man, wondered how one on whom the world's favour shone so
brightly could be so melancholy, almost so morose.

They did not know that years ago, when the Imperial Theatre was
called 'Higg's Hall of Amusement,' Bob Spate, then a young man,
had written several of the comedies which had since so entranced
the world, and had hawked them about here and there to London
and provincial managers, always receiving them back upon his hands
with a half civil, half contemptuous refusal. How was he, they
argued, who was only a fifth-rate actor at a pound a week, to be
able to write a comedy, or even, could he do so, what benefit could
they reap by the production of the work of an unknown man? So
Bob Spate struggled and struggled in poverty, in sickness, and
ofttimes in hunger; struggled on, and saw his wife die, and his
children shrunken and wan and ailing, with the bitter knowledge that
what he had written was better than nine-tenths of what he saw so
highly paid for, but with the conviction that Fate was against him.

When bright little Lotty Bennett made her first attempt at

establishing herself in life, and taking the dirty old Higg's Hall,
changed it into the bright Imperial, she thought that as she herself
was new in management, and she had a new company of actors,
she might try a new author; and remembering Bob Spate, who had
been an old friend of hers, and in whose energy and talent he had
always faith, produced one of his comedies on her opening night.
The success was immense, and from that time Bob Spate's fortune
was made; wealth is his now, and honour, and such position as he
chooses to take. What are they to him? Can they bring back to him
the wife of his youth, whom he saw die by his side, not from actual
starvation, indeed, but from lack of such necessaries as her delicate
condition required? Can they efface from his mind the privations
suffered by his children and himself? Can they bring back to him the
youthful energy, the sanguine hope, the bright happy view of life so
long since fled? I trow not. It is no wonder to me that Bob Spate is
grave and reticent.

Anything but grave and reticent, however, is the gentleman

standing next to him. Mr. Orlando Bounce is the youngest of elderly
gentlemen, the brightest, cheeriest, emptiest rattletrap who for a
half century has been acting light lovers and dashing roués, and
who, if rumour is to be believed, has, during the same period,
played the very same parts in private life. Old-fashioned is a sad
epithet, but it is really applicable to Mr. Orlando Bounce; the peculiar
roll of his blue-black hair, the peculiar side-cock of his shiny hat, his
swinging gait, the elaborate motions of his arms--all these are
essentially old-fashioned; and when he bends in his back, and
throws out his right arm and right leg with studied grace, you are
reminded of Charles Surface, Captain Absolute, and all the riotous,
swaggering young heroes of the comedies of those days. Before the
arrival of Miss Montressor he has been paying great attention to the
two ladies between whom he was standing, but they neither of them
seemed to be much impressed by his attention. 'Get along, 'Lando,
you are always talking such stuff,' is what one of them says to him.
These are Rose and Blanche Wogsby, daughters of old Wogsby,
manager of the northern circuit, and prime favourites in London.
There is an extraordinary difference in their appearance: Blanche is
very fair, with light-blue eyes and delicate skin, and a pretty bud of a
mouth; Rose is tall and angular and swarthy, with dark hair, a strong
jaw, and an underhanging lip--Blanche is a fool, Rose a remarkably
clever girl. 'Blanche Wogsby is a fool,' frankly remarks Mr. Wuff, the
great theatrical impresario, 'but she is always safe for a dozen stalls
a night from the young fellows who are spoony about her; but when
it comes to the question of the tear-and-tatters fakement, when you
want the real grit and no mistake about it, you must go to Rose. She
will turn out a regular Rachel, you may depend upon it!' Mr. Wuff
pronounced this word like the name of the lady who refused to be
comforted, but meant to allude to the great French actress.

All present, both ladies and gentlemen, were, or seemed to be,

greatly delighted at the new arrival. Bryan Duval was a general
favourite. He was so kind and good-natured, so ready to lend any of
his colleagues a helping hand, that they even forgave him his
success. Miss Montressor was popular too, considering her prettiness
and the position she had won for herself; more especially popular
just at this moment, for the news of her American engagement had
got wind, and it was felt that she would be out of all competitors'
way for some time to come.

When the first greetings were over, Bryan Duval proposed that
they should stroll towards the park, and thither they all repaired; Mr.
Foster offering his arm to Miss Montressor, and remaining at some
little distance behind the others.

'Do you know,' said he, 'that I am really very glad to have made
your acquaintance--no, no,' he added quickly, as she looked up in his
face and smiled rather maliciously; 'when I say so, it is not the
ordinary compliment which you evidently imagine it to be. When you
know me better, you will find I am not given to paying compliments,
and that I invariably mean what I say.'

'I am glad to hear it in this case, at all events,' said Miss

Montressor, with a little bow.

'It is the case,' he said. 'I felt interested in you long before I saw
you. The fact is, Miss Montressor, I am a very busy man, far more
immersed in business, environed by it, and tied down to it, than any
of the gentlemen whom I have met here, and who are called your
"City men," and when I am at home in New York the one relaxation I
allow myself is the theatre.'
 This man was a new experience to Miss Montressor, so far more
earnest and dignified than the usual run of her associates. She tried
to fall into his vein, and said quietly:

'I can understand its being a great resource to you.'

'It is a great relief,' he replied, 'in enabling me to throw off, for a

time at least, the dull cares and worries, and to fill my mind with
pictures and stories sufficiently absorbing to prevent its straying to
Wall-street and its ties. I have the pleasure of acquaintance with Mr.
Leonard Serbski; you have heard of him?'

'Certainly,' said Miss Montressor; 'he is the son of old James

Serbski, who was so great in the Bandit, and whose portrait hangs in
all the theatrical print-shops, is he not?'

'The same,' replied Mr. Foster; 'a very handsome and gentlemanly
fellow, and a very good actor. He has heard of you too, not merely
through the medium of the English theatrical newspapers, but from
people who have seen you, and has more than once mentioned your
name to me.'

Miss Montressor was delighted with the compliment, under which

she purred like a cat.

'I had no idea,' she said, raising her eyebrows, and throwing an
expression of childish incredulity, which she knew was very
becoming, into her face--'I had no idea that anybody in America had
ever heard of poor little me; I thought I was going out there entirely
unknown, and that I should have great difficulty in making my way.'

'You will find that you have happily deceived yourself,' said Mr.
Foster, with a smile. 'You will find that we Americans have a much
livelier and deeper interest in all matters appertaining to literature
and art than our more sober cousins on this side the Atlantic, that all
artists of any reputation are known to us, and that when they come
to our shores, they may be certain of a right hearty welcome.'
 'I am very glad to hear you say so,' said Miss Montressor; 'and I
only wish--it is a selfish thing to say, is it not?--that chance had sent
you back to New York before our arrival, that I might be certain of
having at least one personal friend.'

'It would have delighted me to have been of service to you, and

perhaps I may even yet have the opportunity. When do you sail?'

'I think Mr. Duval mentioned the Cuba as the name of the vessel in
which our passage was engaged.'

'The Cuba!' repeated Mr. Foster. 'I am almost afraid that I shall be
unable to get back by her, although I have made such progress in
the business which brought me over here--business, you see, again,
Miss Montressor--that I think it will not be necessary for me to
remain in England so long as I at first anticipated.'

'If you were a married man, Mr. Foster, that would, I imagine, be
very pleasant news to some one who is, what you call, "on the other
side."'

'If I were a married man!-' he exclaimed, with a laugh. 'Why, do

you mean to say, Miss Montressor, that you have any doubt on the
subject.'

'Well, you certainly have what I may call a family look about you,'
she said, casting a careless glance over him; 'but as I have never
heard you mention your wife, I concluded you were a bachelor.'

'I take it as a compliment,' he said, with another laugh, but this

time more nervously and more seriously than before, 'or rather as a
credit to myself, that even in the two short interviews which we have
had since I made your acquaintance, I have not said something
about my wife. It is the humour of most of my friends in New York
to say that--excepting business matters, of course, where I never
permit any domestic thoughts to intrude--that Helen's name is
scarcely ever out of my mouth.'
 'And quite right too,' said Miss Montressor. 'I detest a man who is
married and ashamed of it, and who, when away from home, goes
about, as it were, sailing under false colours. And so Mrs. Foster is
called Helen? It is a very pretty name.'

'And she is a very pretty woman,' said Foster enthusiastically; 'and

not merely that, but the best and dearest little woman in the world.
Here,' he added, plunging his hands into his waistcoat-pocket, and
taking out from thence his watch, 'here is her portrait.' As he spoke,
he placed the watch in Miss Montressor's hand.

Miss Montressor took the watch, and looked at its back, which was
merely of engine-turned gold; then she pressed her fingers all round
in search of some hidden spring, but finding none, shook her head
blankly, and gave it back to her companion.

'I can see no portrait,' she said half pettishly.

'Of course not,' said he, with a laugh. 'You would not have me
carry such a treasure as that for every one to see whenever I
wanted to know the time. There,' he added, as the spring flew back
and revealed the miniature, 'now you see my darling.'

'What a sweet face!' cried Miss Montressor, clapping her hands; 'so
soft and pensive and loving! I don't wonder at your being fond of
her, Mr. Foster, or being anxious to get back to her.'

'She is all that you say,' cried Mr. Foster, 'and more, God bless her!'

'It is quite refreshing, in these times of separation and divorce

courts, and all that sort of thing,' said Miss Montressor, 'to find such
regular spooniness existing between a married couple. But if you are
so fond of each other, why on earth didn't you bring her with you?'

'Didn't I tell you that I came over here on business, and that I
never allowed even Helen to interfere with me when I am so
engaged? Besides, she could not leave the child, which is indeed,'
said Mr. Foster, 'the sweetest and most engaging--'

'Yes,' interrupted Miss Montressor; 'you may spare your rhapsodies

about him, or her, or it. I don't go in for babies.'

'I am sure you would feel interested in her, if you only saw it; not
merely is she the prettiest, tiniest mite, but she would move your
sympathy for her bad health.'

'It has bad health, has it?' asked Miss Montressor carelessly.

'Very bad,' replied Foster. 'My wife's strength is scarcely equal to

the discharge of her maternal duties, and she has had to engage a
wet-nurse for the little one.'

'I hate wet-nurses,' said Miss Montressor shortly.

'They are not generally very trustworthy,' said Foster, 'but from a
letter I have here' (producing one from his breast-pocket, and
opening it), 'we seem to have found an exceptional treasure. Helen
writes me in the strongest terms of the respectability of Mrs.
Jenkins.'

'Mrs. Jenkins?' replied Miss Montressor, pricking up her ears. 'Who

is she?'

'The wet-nurse of whom I have just spoken to you. You ought to

have a kindly feeling towards her; for Helen tells me that she is an
Englishwoman, and married to an Englishman for some time settled
in New York.'

An instantaneous gloom spread over Miss Montressor's face, and

she walked on by her companion's side in silence. Mrs. Jenkins? The
name was common enough among English people, and yet a
horrible feeling of fear crept over the young woman who chose to
call herself Clara Montressor--a feeling of fear lest this Mrs. Jenkins,
now occupying the situation of wet-nurse in Mr. Foster's family,
should be none other than her own sister Bess.

She had not heard from Bess for months, but the last letter was
dated from New York, and spoke of the shifty, hand-to-mouth
existence which she and her husband were leading. Could it be
possible that they could have fallen so low, that poverty could have
come upon them so rapidly, as to induce her to undertake such a
menial position? Was her husband dead? could he have deserted
her? or what was the cause of her sudden collapse?

The more she thought over this matter, the more angry and
impatient she grew; and Mr. Foster, noticing her preoccupation,
thought it best not to attempt to renew the conversation just then.

Did ever anything happen so unfortunately? At any other time it

would not have mattered in the least. Between Bess Jenkins, the
wet-nurse in New York, and Clara Montressor, the theatrical star in
London, there was a great gulf fixed; but when the theatrical star
shifted its orbit to the city where her humble relation was living, the
latter would naturally and undoubtedly proclaim to the world the
family tie existing between them, and endeavour to make the most
of it to aid her fallen fortune.

What should she do? what should she do? The saturnine face of
Mr. Dolby rose before her mind in a minute. How should she treat
him in regard to this matter? Certainly not tell him, for more reasons
than one. He would be the last man in the world from whom she
would receive any sympathy, and, besides, she does not choose to
let him know the fact of the relationship. Towards him, then, she
would preserve absolute silence; and a little further reflection
decided her that her best plan was to wait, become better
acquainted with Mr. Foster, and if she found him the good and
honest man which, from her slight acquaintance with him, she
fancied him to be--for even with her associates, and her experience
of the world, she still believed in goodness and honesty--perhaps tell
him the truth, and get his help in suppressing it. Yes, that was the
course she would take; and having determined on it, she put the
subject aside, and looked up at her companion, as though to say she
were ready to renew the conversation.

'How pensive you have been!' said Foster earnestly. 'I did not like
to break in upon your reverie.'

'I am very much obliged to you for leaving me to myself for those
few moments,' she said, with a laugh; 'it doesn't sound
complimentary, but it is true. You see, I am about to take what may
be a rather serious step in my life, for if I succeed in America, my
career is certain, and if I fail it may be wrecked, not merely there,
but here; ill news travels apace, and it would soon be known that
the London star had made a fiasco.'

'Even then, former experiences prove that your compatriots would

retain their opinion of their favourite, and decline to accept our
verdict,' said Mr. Foster. 'However, you need not be under any
apprehensions of the sort; as I have told you before, you are sure to
succeed.'

'I have great faith in Bryan Duval,' said Miss Montressor, 'and full
reliance upon his generalship--he is popular too in New York, I
understand.'

'Very popular indeed,' said Mr. Foster; 'he has achieved what is
rather difficult there, a society reputation. This reputation he
apparently wants to extend, for he has asked me for an introduction
to my wife.'

'And you have given it to him?'

'Well, no,' said Mr. Foster, rather confusedly. 'There are--there are
some reasons why I could not do so conveniently--in writing, I
mean. Of course, I should be only too glad that both he and you
should know Mrs.--Mrs. Foster, but I prefer waiting to introduce you
personally on my arrival in New York; in case I cannot, there is yet a
chance of my leaving by the same steamer. I see the others are
making for the hotel, and I suppose, in my capacity of host, I ought
to be the first there.'

It was a very good dinner, and went off remarkably well. In

addition to the company already named, there were present Mr.
Wuff, the celebrated manager of the Great National Theatre, who
was supposed to be devoted to the legitimate drama, and where the
performances at present consisted in a short farce, followed by a
long 'oriental spectacular burlesque,' introducing horses, elephants,
camels, and dancing women; Viscount Koolese, who was supposed
to be ruining himself for Mademoiselle Petitpois, who brought with
him his friend Captain Clinker, the well-known gentleman rider, who
said nothing, but whenever he was amused hissed loudly through
his teeth as though he were cleaning a horse; a sound which
seemed very unpleasant to the theatrical people present. There was
another manager too--Mr. Hodgkinson of the Varieties--who kept up
a running fire of argument throughout the dinner with Bryan Duval;
the actor-author, whether he believed in it or not, maintaining that
the drama should be the school of poetry and refinement, and that
all the theatrical managers should be made with a view to that end--
sentiments which Mr. Hodgkinson violently pooh-poohed, declaring
that his chief aim was to give whatever amusement paid the best.

'Let 'em have it,' said Mr. Hodgkinson, who prided himself on
being an eminently practical man, striking his fist upon the table;
'dogs and monkeys, Shakespeare, the "Perfect Cure," Tom Mugger in
four farces a night; or old Bounce here as Charles Surface, and all
the rest of the Sheridan fakement--and the public is always wanting
one or other of them, and my notion is, give them all a turn.'

Mr. Foster had placed Miss Montressor on his right hand, and
though there was, of course, no opportunity and no occasion for
returning to the subjects which they had touched upon in the park,
he kept up a constant conversation with her. When the party was
about breaking up, he proposed that she should return to town in
his Victoria, where, as the night was somewhat cold, she would be
warmer and more comfortable than in Bryan Duval's phaeton. Miss
Montressor gladly accepted the offer, and, of course, Mr. Duval made
no difficulty. He would, he thought, propose to drive Blanche
Wogsby home, and take the opportunity of finding out whether she
was really such a fool as she looked, or whether there would be any
use in writing a part for her.

So the party broke up and the guests dispersed, and Bryan Duval,
in taking farewell of Miss Montressor, told her that if the letters
which he expected in the morning arrived, he should be able to let
her know for certain the day of sailing for New York.

'It has been a delightful day, Mr. Foster,' said the actress, as they
drove homewards, 'and I have enjoyed it immensely. Will you be
able to give us any such outings in America?'

'I hope many such,' said Mr. Foster; 'but unless you take more
care of yourself, I fear you will not be there to enjoy them. Seriously,
your English spring weather is proverbially treacherous, and the
wind tonight has a touch of east in it, which should induce you to
wrap your shawl more closely round you.'

'I want to wrap myself up,' said Miss Montressor, justly estimating
the truth of his words, 'for I am particularly susceptible to cold, but I
cannot for this bothering pin.'

'What is the matter with the pin?' said Mr. -Foster, laughing.

'It is not half strong enough to hold the shawl together. I cannot
imagine how Justine sent me out with such a stupid thing.'

'Perhaps this will prove more effectual?' said Mr. Foster, taking the
breast-pin from his cravat and offering it to her.
 'Thanks very much,' she cried, accepting it with great readiness.
'What a very pretty pin! I love these cameos, and this is such a
good-looking boy, with a straight nose and a queer cap on his head.'

'A Phrygian cap,' said Mr. Foster, laughing. 'It is a head of

Ganymede. I had it set as a pin, I thought it so handsome.'

'Do you mean to say you brought it with you from Phrygia, or
wherever it is?' asked the actress, who was vague in her geography.

'No, no,' said Mr. Foster, laughing still more; 'but it was a sleeve-
link when I first found it among my clothes when I opened my
portmanteau in London. I suppose it belonged to my wife, as she is
fond of such things, and that it was put up with my things by
accident.'

The shawl comfortably pinned round her, Miss Montressor settled

herself down to her corner, and neither she nor her companion
spoke much more, being occupied with their own reflections. But
when Mr. Foster took leave of her, he reminded her of Bryan Duval's
last words, and told her that if he were prevented from sailing in the
Cuba, he should certainly accompany the theatrical party down to
Liverpool, and take leave of them on board.

Miss Montressor had been in very good spirits all day,

notwithstanding the annoyance which, as we have seen, one portion
of Mr. Foster's communication had caused her. She was agreeably
conscious that her looks had been at their best. She was sufficiently
refined, more by nature than by education, to recognise a gentleman
when she met one, and to enjoy the ease and security conveyed by
association with gentlemen. Mr. Foster had struck her from the first
as a gentleman; not very brilliant indeed, but kind, courteous, and
considerate--the sort of man who did not make women
uncomfortable by either his looks or his language--and Miss
Montressor appreciated this. She did not belong in the least to the
reckless class among her order, and she had an almost morbid
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