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Supervision in midwifery practice

16 June, 2008

Supervision in midwifery practice

This paper begins by describing the problems encountered by midwifery staff in their practice and continues with the introduction of supervision in the field of midwifery. This is a didactic and supportive method that might encourage and enhance midwives’ professional development and personal growth. Midwifery can be very demanding emotionally. It imposes external demands and, in addition, some midwives expect too much of themselves. Clinical supervision can help the midwives to reduce stress and prevent em

Mihaela Skoberne is a senior lecturer at the College for Health Studies, University of Ljubljana 

Midwives magazine: February 2003

This paper begins by describing the problems encountered by midwifery staff in their practice and continues with the introduction of supervision in the field of midwifery. This is a didactic and supportive method that might encourage and enhance midwives’ professional development and personal growth. Midwifery can be very demanding emotionally. It imposes external demands and, in addition, some midwives expect too much of themselves. Clinical supervision can help the midwives to reduce stress and prevent emotional fatigue, which often leads to lack of both enthusiasm and motivation at work. 


‘As the old man walked the beach at dawn, he noticed a young man ahead of him picking up starfish and flinging them into the sea. Finally catching up with the youth, he asked him why he was doing this. The answer was that the stranded starfish would die if left until the morning sun. “But the beach goes on for miles and there are millions of starfish,” countered the other. “How can your effort make any difference?” The young man looked at the starfish in his hand and then threw it to safety in the waves. “It makes a difference to this one,” he said.’ (Veatch and Fry, 1987)


During her working career a midwife encounters several ‘starfish’. It is her knowledge, effort and willingness that determine the midwife’s approach and attitude to treating them. Supervision can induce positive changes in the field of midwifery and consequently influence the life of the ‘starfish’ as well as the work and life of the midwives themselves. There are numerous reasons for introducing supervision in the everyday practice of midwifery. This paper will begin with the presentation of one case in order to better explain the concept of supervision and justify its adoption in the everyday practice of midwifery care.


The following distressing story was told by a student of midwifery. She was attending a young mother and witnessed the death of her newborn girl due to congenital disorders (spina bifida and hydrocephalus). After the tragic event, the student went to the midwives’ room to have a cup of tea. Only then she realised the full extent of the tragedy and started crying inconsolably. Instead of showing sympathy and calming down the student, one of the senior midwives criticised her behaviour and ordered her to continue with her daily routine.


This reaction shows a complete lack of understanding and compassion for another person. But can we expect a health professional to empathise with her clients and recognise their needs if she has no understanding for her colleagues’ and co-workers’ feelings?


Most midwives feel that their workload is too great. Their clients’ physical, emotional and psychological problems are the most painful issue. Therefore they should learn to support each other and develop and nourish a high level of sensitiveness toward their coworkers and clients in order to realise the culture of midwifery practice. This common understanding is a prerequisite for spontaneous expression of their feelings in time of stress. The method that can be successfully used to explore one’s feelings in time of stress is the systematic approach of supervision (Skoberne, 1996).


Definition of supervision


The meaning of the term supervision is multifold. It can be defined as a control, when the effectiveness of one’s actions is observed. As supervision can also be interpreted as counselling, and a more detailed clarification of its significance is necessary. The word is of Latin etymology (super — over, videre — stare). The present use of the term should be defined according to the working context. It means either ‘a look from above’ or ‘a look from the distance’. In its figurative sense, it can be understood as ‘seeing things and events in the right perspective’. To avoid confusion, some authors suggest that this working method be defined descriptively, i.e. ‘a perspective from outside’, ‘a process of pondering on the effective implementation of our work affecting other people’ (Kobolt and Zorga, 1999).


There are several definitions of the term supervision. Hess (1980) defined supervision as ‘an interpersonal relationship between a supervisor and a supervisee with the aim of achieving the supervisee’s higher quality of work with his clients’. A client in this context represents a person with whom the supervisee (a professional) has an intense and close contact.


Ann Luttinkholt (1987) described supervision as ‘a process of teaching and learning where a person possessing certain knowledge and skills assumes the responsibility for teaching an individual with less knowledge and skills’. 


Dekleva (1995) considers supervision as ‘a special process of learning, the aim of which is to encourage the reflection and self-reflection of the trainee, thus enhancing his/her professional competence, especially in the fields where working with people is emotionally and methodologically demanding’.


Supervision is thus one of the possible learning processes through which a professional can gain insight into his own problems encountered in her/his working practice and find a way to better cope with stressful situations. It helps her integrate her practical experiences with theoretical knowledge and transfer the theory into practice. The final goal pursued is the autonomy of her/his professional performance. The important aspects of supervision are also the search of one’s own professional identity and the awareness of the possible and actual professional roles, as well as the responsibility and commitments accompanying these roles (Kobolt and Zorga, 1999).


Along with different definitions of supervision, there is also a diversity of supervisees’ expectations concerning this teaching/learning method. A student of midwifery care has understandably different needs from an experienced senior midwife.


During one of her supervision sessions, Gaie Huston (1990) posed a question concerning the participants’ expectations. A young therapist replied: ‘Of course I want supervision. I want to get to the core of the matter. I want real SUPER-vision.’


The development and the role of supervision


Supervision as a method of introducing a professional worker into her/his professional practice, including counselling, instruction and support, was initially used in the field of social work in the US and UK at the turn of the century. Due to the lack of properly qualified specialists in social work, these services were performed by volunteers, mainly women. Therefore the necessary supervision and monitoring of these activities was entrusted to experienced and trained social workers. Thus supervision came to be recognized as a form of education and control over the volunteers’ performance (Kobolt, 1999).


Later, supervision was used also in other fields where the interpersonal relationships among caring professionals and others (health care, schools) are of significance.


The supervision process was used selectively according to the needs of a specific profession, but the following important dimensions or functions are always considered (Kobolt and Zorga, 1999):

  • The educational function

  • The supportive function

  • The managerial function.


Theoretical models of supervision in midwifery


What are the reasons for not having introduced supervision into the field of midwifery earlier? It may be that the clinical specialists in midwifery have only recently recognised its importance in achieving highquality care in midwifery. In order to satisfy their patients’ physical, emotional, spiritual and social needs, midwives must also establish sincere relationships with their clients.


Supervision in midwifery must develop and adapt to the needs of this clinical specialty. It should include all the elements of education and support, but remain flexible and non-dogmatic. The clinical models of supervision can be developed upon the knowledge base and experience from the field of psychodynamic, behaviouristic and humanistic — interpersonal, biological and social theories (Butterworth,1992).


Personal and professional development


Working with clients requires midwives develop certain skills and responsiveness. Clinical supervision may enhance this development.


According to Piaget (1970), personal development is the result of two processes — assimilation and adaptation. These are elicited when a midwife during supervision, recognises certain unsatisfactory or inappropriate facts. Assimilation is a process whereby new information is incorporated into the existing schemes of reasoning.Without this assimilation process, the process of learning is incomplete and the personal growth and professional development are hindered.


Supervision helps midwives become better practitioners and explore those areas in themselves that might remain restrained. The supervision process can show the way to self-awareness by helping a midwife thoroughly examine her inner self and her feelings. This adds to the identification of one’s own strengths and weaknesses.When the latter are eliminated, she can broaden the scope of self-understanding and better help the clients in need.


Some general information on supervision


Different authors describe the supervision process as consisting of three (Farkas- Cameron, 1995), four (Dutch model) or five stages respectively (Goldhammer et al, 1980). The four main stages and phases as defined by Zorga (1999) are as follows:

  • Preparatory stage

  • Introductory stage

  • Implementation stage

  • Final stage


Supervision is a reflective process through which professional workers enhance their personal growth and professional development. The goal of supervision is to encourage learning by reflection, through which new knowledge and skills will be gained along with the access to one’s feelings and intuition. In pursuit of this goal, reflection is neither spontaneous nor automatic. It is an active and systematic process of searching and uncovering, which must be learnt (Tancig, 1994). Through several models of supervision, supervisees can gain access to personal knowledge of a particular discipline or experiences. This knowledge helps them better cope with their everyday problems and become more efficient in their work.


As it is evident from the given definitions, supervision includes at least four elements (Hawkins and Shohet, 1992):

  • A supervisor who leads the supervisee during the supervision process

  • A supervisee (a midwife who wants to learn)

  • A client

  • The working context.


The first two are obligatory during a supervision session, while the client and the working context are consciously or subconsciously presented through the supervisee’s story.


Supervision as a didactic method can be used only after a supervisee (a midwife or a student of midwifery) has started working with clients, that is, when the theoretical knowledge has been applied into real life situations.


Clinical supervision can take the form of a face-to-face discussion between the supervisor and the supervisee, or in a small group, which is an ideal form of supervision. According to Henk Hanekamp (1992), the optimal group consists of the supervisor and three supervisees. The ideal supervisor is a person who possesses the necessary professional knowledge in the field of supervision and who can create a restful, relaxed and trustful atmosphere.


Northcott (1996) claims that the role of the supervisor is crucial. Therefore it is necessary that they:

  • Qualify for this role and continually update their knowledge

  • Engage in their own supervision

  • Are secured a constant support and help in their professional endeavours

  • Are recognised as experts in this field of clinical practice.


Supervision involves personal and cognitive as well as emotional levels.We must be aware of the fact that learning through supervision is trying, and occasionally also painful. In the latter case, the supervisor is expected to encourage and support, sometimes counsel, but never judge.


Hanekamp (1994) claims that: ‘Supervisors can only become those individuals who are honest toward their supervisees and themselves. They should be able to choose the right words to tell the truth about themselves and their supervisees without offending anybody’s feelings. Their communication should reflect warmth, respect, positive regard and genuineness. They must make the supervisees feel accepted and open, rather than threatened and defensive. The main task of the supervisor is to support the supervisee in her challenge to risk and grow by choosing his own way. All this is possible only if the supervisor loves herself and manifests her love of other people and the world, if she does not hesitate to reveal her own directions in life and the consequences of her decisions. The supervisees are then free to choose, to take their own responsibility and be happy in their mission.’


The nature of relationship between the supervisor and the supervisee is greatly influenced by the working agreement, which includes some basic rules for work and the information about:

  • The goal of the supervision

  • The meeting place

  • Number, duration, time and frequency of these meetings

  • Obligations of the supervisor and the supervisees (the latter can write a report of reflection and evaluation of the supervision process).


The participants may also discuss their expectations and fears connected with relationships established during supervision. All the participants should respect this agreement.


The topics discussed during supervision in midwifery may include:

  •  The analysis of a specific problem or event experienced by the supervisee

  • The necessary skills, support and evaluation of the therapeutic approach

  • Self-evaluation and self-awareness _ Management and counselling

  • Burnt-out syndrome

  • The validity or confirmation of the professional and interpersonal procedures of the supervisee

  • Feedback information on the supervisee’s work

  • Discussions about the traumatic events and the supervisee’s effectiveness in coping with them

  • The advantages and disadvantages of protective mechanisms in mastering such traumatic events.




The paper presents just a few important and encouraging aspects of supervision. However, these should suffice that midwives recognise the value and welcome the experience of supervision already at the beginning of their working career. Even more, it should become an integral part of their working practice, their continuous personal growth and professional development. It is widely agreed that supervision may also add to the humanisation of the discipline as such.


Supervision may help midwives fulfil their professional roles and reach a higher quality of their work. It should be emphasised that their professional knowledge and skills no longer suffice to perform their tasks effectively. They should develop skills to control and cope with their feelings of inadequacy and vulnerability that might lead even to the burnt-out syndrome. Supervision proved to be much more effective in this respect than the traditionally practised relaxation techniques or yoga.


However, midwives should not expect too much from supervision because they are still limited in their professional endeavours by things that can not be changed or improved. When these limitations were discussed, our teacher, Henk Hanekamp, asked us to discover our personal sphere of influence, i.e. to learn to control the things we need to control, accept the things we can not, and develop the wisdom to differentiate between the two (Workshop on supervision, Netherlands, 1992-1994).




Supervision was introduced into nursing curricula at the College for Health Studies in 1996. The syllabus was the result of common efforts of the three teachers who had completed their two-year specialisation in the Netherlands in 1994.




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