Abstract
This study investigated clinical supervision with Allied Health professionals in a public health setting. Staff perceptions and experiences were explored through focus group discussions. Key themes identified that supervisees “tip-toe into complexity” by engaging in reflective practice for incremental personal and professional development. In contrast, supervisors identified that reflexivity was required for the opportunity to “develop at a deeper level”. Offering a choice of supervisor and providing supervisor training enhanced supervision experiences. Challenges to effective supervision were identified. Competing priorities, inconsistent modes of delivery, major organisational change and the role of clinical supervision in line with professional development confounded the experiences. Health managers could improve the processes and outcomes by implementing consistency with approach, timing, documentation, language, and structure of Clinical Supervision.
Introduction
Clinical supervision (CS) is credited as one of the foundations of clinical governance to provide safety and quality outcomes for patients in all aspects of healthcare. 1 The aim of CS is to reduce risk through evidence-based ethical practice. 1 Definitions of CS change according to the country undertaking the activity, 2 the discipline 3 and whether the supervisee is a health student or clinician. 4 In Australia, CS is an integral component of health discipline student supervision, which is continued in the clinical setting after graduation. 5
As a requirement of Allied Health professional practice 6 the aim of CS is to develop staff knowledge, skills and attitudes. 7 The intent is to develop capability through personal, professional and educational support. 8 Allied Health (AH) staff satisfaction, confidence and competence in everyday practice and complex situations can be enhanced. 8 However, there is little documentation of the processes to assist personal and clinical development and how the benefits to staff are transferred to patient safety and outcomes. 1
Clinical Supervision encompasses many models, 8 with a reflective model being the most widespread in AH. 9 Supervision can be provided by senior or peer colleagues in a dyad or group intervention, either intra- or inter-professionally. 7 The three primary functions of supervision are to focus on clinical skill development, 10 professionalism 11 and emotional support. 12 These are intended to enhance AH practice, work situations and environments in varied organisational and staff settings. 6 Within a local Australian metropolitan health network incorporating a large tertiary hospital, a sub-acute hospital, and a community hospital, AH staff were mandated to participate in CS. However, the results of a local quality assurance survey indicated poor understanding of the process of CS and how it assisted with clinical development (personal communication, 2017). In light of varied content of CS, 9 and the influence of CS on professional or career development, 13 the aim of this project was to explore AH staff experiences and perceptions of CS to inform standardized practice. This qualitative study therefore explored AH staff perceptions of CS, the processes surrounding CS and the perceived impact of CS on AH clinical practice to inform future practice.
Methods
A qualitative phenomenological-based approach explored AH staff’s lived experiences and perceptions related to CS. 14 Focus groups were chosen to elicit and encourage reflection and discussion of the processes and impact of CS between participants. 15 Neutrally worded, open-ended, semi-structured questions formed an interview schedule 15 (Appendix 1). Ethical approval was provided for three metropolitan hospital sites by the regional ethics committee (HREC #393.16).
Currently employed AH professional staff who worked in the three regional hospitals were eligible to participate if they received CS; other clinical staff including AH assistants and students were not included. Staff were invited to participate in focus groups across the three hospital sites within the network. Flyers were distributed via Allied Health managers who were independent of the research. Interested participants registered for a focus group and received the study information sheet. At the commencement of each focus group, the participants provided written informed consent and demographic information. Six, one-hour focus groups were held in private areas for 3-8 participants, until data saturation was considered complete. Two or more members of the research team attended each focus group to ensure consistency in approach, provide reassurance to participants and encourage deeper discussion for specific examples or further information. 15 All sessions were audio-recorded with additional written notes taken to enable member verification. Audio recordings were transcribed verbatim by two of the research team and all potentially identifying information in the transcripts was removed. Transcriptions were entered into NVivo (QSR International) for data analysis and coding. Two of the research team independently identified initial concepts from the first focus group, relating the data back to the research questions for relevance. This process was repeated for subsequent focus groups before these concepts were discussed as a full team. Discussion on concepts, with reference back to the research questions and examination of researcher reflexivity, led to the key themes being revealed. 14
Results
Twenty-five AH clinicians (96% female; aged 22–61 years (mean 36.6 ± 9.9 years)) from six disciplines (speech pathology n = 12, podiatry n = 5, physiotherapy n = 3, dietetics n = 2, social work n = 2, and occupational therapy n = 1) had a mean of 11.8 (±11.1) years of experience. Participants had undertaken CS as supervisee or supervisor an average of seven (±10.3, range 0–40) times in the previous 2 months. All participants supervised other AH clinicians or AH assistants.
The main themes to emerge represent three entities: supervisees’ experiences, supervisors’ perceptions, and the priorities, challenges and bigger picture of the system in which CS occurred. Direct quotes from the participants provide the titles to describe the themes. These and direct quotes are presented in italics and do not identify individuals or their discipline to maintain anonymity.
“Tip-toe into complexity”
The supervisee theme “tip-toe into complexity” highlighted that CS was for incremental personal and professional growth. The process for development was described as feeling “validated and feel valued and feel safe, but also to be able to be challenged”. There were both positive and negative aspects of CS that influenced supervisees’ perceptions of its value and effectiveness. All participants recognised the value of the “safe zone” of an uninterrupted conversation with their supervisor and how this supported clinical development “to know your own skill set but take those really calculated, measured, supported risks”.
The trust required for these conversations lay in the open, non-judgemental nature of discussions to “fix it at the time and reflect back on it in supervision”. The allotted time for CS provided safety to reflect on broader concepts beyond the immediate patient need, for “higher level of processing, not just attacking the daily task”. Reflection on the quality of supervision was also identified. For example, “without supervision, you run the risk of just doing the same thing… You could be doing the wrong thing over and over again”.
The content of CS discussions varied greatly and encompassed multiple tasks: clinical debrief, competency development, personal goal identification, preparation for leadership, and development of clinical reasoning not necessarily related to patient care. The content and structure also differed according to the urgency of the dialogue. For newer graduates this often related to safety concerns. Participants described urgent conversations as “informal” or “reactive” CS. This occurred without pre-arrangement, “in-the-moment”, and not necessarily with the nominated supervisor. Further, content changed from development of new or enhanced clinical skills as a new graduate, through supervision skills as an emerging senior clinician, to management and leadership skills as an advanced clinician. The sessions provided an opportunity to reflect on complex situations or interpersonal communication. For example, “it was mainly all that clinical health and patient relationship, health communication…dealing with the different personalities”.
Participants reported benefit from both reactive and structured CS sessions. This challenged the “rigid view on what supervision is and how it should be delivered”. Planned CS sessions were enhanced if there was an agenda and clear goals to “problem-solve more complex cases in a structured discussion”. This identified respect for the partner’s time commitment within a very busy workload so that “there is an outcome, so it’s not just ‘We’ve had a chat’”.
Limited preparation was justified by time constraints, particularly in the context of a very busy caseload. Additionally, numerous mandated activities, both clinical and non-clinical, placed CS as a lower priority. For example, “time-poor [people] who are highly stressed, supervising other time-poor, highly-stressed people”.
Different modes of supervision were discussed as part of structured sessions. These included group, peer and interprofessional supervision. Group supervision was primarily undertaken for activities such as checking off competencies. Whilst group CS sessions had the advantage of efficiency and effectiveness for skill competency sign-off, they were difficult to arrange for several busy clinicians, and not perceived to permit frank discussion, address individualised needs, nor allow conversations of a personal or confidential nature: “You lose a bit of that trust being able to talk about failures and things that are hard, or things that you are finding overwhelming”.
Peer supervision was considered helpful for debriefing or emotional support. Peer supervision was described as brainstorming treatment options with a colleague or sharing responsibility for service development. Informal clinical meetings throughout the day, such as journey board meetings or ‘huddles’ were also considered peer supervision. These sessions were often interdisciplinary with the emphasis primarily on immediate patient needs. Interdisciplinary CS provided “perspectives about different ideas for the same patient” but also presented disadvantages, particularly when the supervisor was not fully aware of the discipline-specific work undertaken by the supervisee “…having to explain what my role was so they had an understanding, and it was just too hard”.
“Develop at a deeper level”
The second theme to emerge related to supervisor traits and preferences. Participants discussed particular supervisor traits that enhanced both supervisor and supervisee development “at a deeper level”. A mutually respectful relationship and trust were considered essential. A good supervisor identified each supervisee’s strengths and weaknesses to support the individual. For example, “the role of the supervisor is to give enough skills for any of the pieces of the puzzle for you to come up with a solution”.
Participants preferred their supervisors to be “another clinician who inspires me… who I really respect, who has been doing things similar to what I want to achieve with my goals”. Importantly, participants preferred to have choice of supervisor over having one nominated so that “the right clinical supervisor [that] fits with you”. A good supervisor was seen to have an open communication style to “practise some of those crucial conversations or coaching-type skills”. Similarly, a healthy supervisor-supervisee relationship facilitated a collaborative approach with “tentative enquiry around sharing experiences but not dictating what to do”.
Supervision relationships were difficult to establish due to time required to build trust, described as “a long game, it's not the short game”. Longer-term supervisor relationships supported both immediate and future development, addressing “not necessarily your skills, it’s your approach as a practitioner across the board”. Conversely, supervision was negatively impacted when the supervisor changed due to clinical rotations every three to four months.
All participants had completed the minimum requirement online CS training modules provided by the health network, and several had also completed the ‘supervisor’ component of the online training. This online supervisor training received mixed feedback. “You learn to cheat at them ‘cos you haven’t got time… What have I learnt? No idea! Got the certificate, that’s all they need.”
Some participants had not undertaken any further supervisor training and expressed an awareness of their limitations with CS. For some it was “on-the-job training… my own learning, self-directed learning, or role models that I've seen”, whereas other participants had undertaken additional face-to-face supervisor training. This latter group identified the benefits of experiential learning to enhance supervision skills. Experiential learning feedback was considered a “good thing…as opposed to learning from another supervisor, [is] you don't want to be passing on potentially a bad habit or a bad trait”.
Participants identified the need for supervisor flexibility to accommodate all supervisees, including “individuals that come to you and they think it's a complete waste of time”.
“Priorities, challenges and the bigger picture”
All participants agreed that CS was important; however, they simultaneously considered it less of a priority than patient care. Therefore, it presented a challenge to quarantine time for CS, for example “Placing importance on clinical supervision so it doesn't get pushed to the side. But at the same time, priorities, you know? There’s a patient that has to be seen”.
Quality and safety for patient care was considered a component of CS. It extended beyond immediate patient care to include supervision of others, research projects, or quality assurance activities: “A particular project you might want to look at and analyse something, maybe some data… bigger picture”.
All participants in this research project supported CS. However, the process, content, and mode of CS differed within and between disciplines and health sites. Differences included the ability to choose a supervisor, the length of supervision partnership, CS expectations or workload allocation in relation to CS. Participant engagement in CS was impacted by organisational changes or in times of system uncertainty.
The duration of the CS sessions (30–90 min), and the frequency (2-weeks to 2-months between sessions) varied greatly between participants. There was no consensus on the ideal timeframe, particularly when the informal, reactive patient discussions met urgent safety requirements. Clinical supervision was seen to enhance future patient care by reflexion – acting on the reflection of a recent patient experience to enhance the treatment for the next patient. “So, I don’t think it has necessarily helped me change an outcome. It’s helped me, not for the current client, but if I reflect back, how I practice in future”.
The role of CS for immediate patient care was clearly articulated. However, there was confusion regarding the definition of CS and its function relating to clinical education, mentoring, professional development, or performance review and development (PR&D). Participants had various opinions regarding the overlap between CS and these other roles, reinforcing the diversity in definition of CS. For example, career development was considered implicit in both CS and PR&D, but CS provided the process while PR&D provided the outcome. For example, “we use PR&D as an opportunity to stop, reflect, maybe reset new goals that might shape supervision”.
Participants also differed in their opinions regarding the value or appropriateness of having a line manager who was also their clinical supervisor. This was particularly the case when CS discussions integrated performance management. Those participants who were supervisors identified that managing both roles was straightforward in theory but difficult in practice: “separating line management from clinical supervision and making it clear that one is not necessarily reliant on the other”.
Supervisee participants expressed concern with engaging frankly in delicate conversations with supervisors who were concurrently the line manager, highlighting challenges such as maintaining confidentiality, particularly within small departments. “You keep your formal supervision quarantined with the person in your clinical area”.
Participants considered CS as a reflective process and an essential component of clinical governance to support aspects of quality and safety in patient care. The parallels with professional development were apparent with the reflective component. However, CS was considered a continuous process, using “structured guided reflection. Professional development is more a learning opportunity, upskilling [to] expand your knowledge”.
Similarly, the difference between CS and mentoring related to the volitional nature of seeking feedback. “Supervision, as opposed to mentoring, is a little bit more about quality assurance...mentoring is more about that moral support”.
Discussion
This body of research identified Allied Health clinicians’ perceptions and experiences of clinical supervision. Supervisees described ‘tip-toeing’ forward to manage ever more complex clinical situations. Supervisors identified developing themselves and their staff at a ‘deeper level’. Both supervisors and supervisees identified challenges with priorities, time management and undertaking CS as a necessary component within the ‘bigger picture’. All staff agreed that a structured approach with explicity expectations was necessary for effective supervision.
There were differences in interpretation of the intent of CS. Participants identified the importance of CS conversations to develop personally and professionally. In this setting, all the CS was conducted in a reflective model, as usual within allied health. 9 This differs from the direct CS model preferred by nursing and medical professions, where the focus shifts to discipline specific skills as opposed to interpersonal or emotional responses. 3
In this study there was strong emphasis on formative skill-building identified in this project, for staff to ‘tip toes into complexity’ which is appropriate for early career clinicians.10–12 The lived experience of staff identified that trust was an essential component of a productive CS relationship. Trust permits difficult, non-judgemental conversations, and provides the safe zone to discuss failures as well as successes. It is clear that, providing patient safety is not compromised, failure can be a powerful tool for learning. 16 The ‘tip toeing’ also aligns with the stages of transition theory in which the first 12 months of clinical practice following health discipline graduation requires a focus on practical skill development and formal support structures. 17 While most research on CS has focused on new graduates or early career clinicians, 18 increased seniority in some of these participants identified more reflexivity, where the focus was on better understanding self and the affective or relational aspects of being a clinician. 19 This reinforces the connection, empathy and rapport required for effective interpersonal relationships at work, including and beyond the CS dyad. 20
Supervisor effectiveness with interpersonal communication skills, caseload familiarity and supportive relationships aligns with existing literature on the characteristics of effective supervisors. 21 Compromised learning was perceived to have occurred when the supervisor was from another profession, was off-site, or was concurrently the supervisee’s line manager. Since this study was conducted prior to the Covid-19 pandemic, remote supervision has become more routine due to necessary distancing. Principles associated with remote supervision remain, including timing, duration, and mode of communication; agreements on scope and limits of discussion; and the options of both synchronous and asynchronous discussions. 22 Supervision from another discipline is increasingly necessary due to workforce availability, particularly since Covid-19. This can be frustrating, as described here, when the supervisor has limited knowledge of the supervisee’s scope of practice. However, there is also emerging evidence of positive and creative approaches from interprofessional supervision, particularly when the supervisor has been chosen by the supervisee. 23
The power differential within the CS relationship was seen by some participants to compromise trust when supervision was provided by a line manager. This can be mitigated by facilitating clinical objectives and focussing on shared problem solving for complex clinical presentations. 24 The mode of CS varied between one to one, incidental, peer, and group supervision according to situation, need or urgency. Advantages of formal, structured CS were the goal setting, individualised and documented progress for the individual. However, allocating time within busy clinical caseloads meant staff often prioritised direct patient care and were not available for the scheduled CS session. The incidental or informal CS met the urgent requirements of safety for immediate patient care; however, the lack of documentation or recording for these discussions made them difficult to track. The advantages of group CS for competency sign-off or content-specific skills were countered by the lack of confidentiality and timetabling requirements for a large number of clinicians.
Training is essential for supervisors. 25 While online modules are easily accessible and available for fact-based and self-paced learning, multi-modal training and interpersonal communication practice provides the supervisor with additional skills and awareness of their own strengths and limitations. 26 Competency-based approaches with interpersonal components provide more targeted training to enhance staff support, staff education and patient outcomes. 27
The final theme in this study was the challenges associated with the ‘bigger picture’ of patient care within the system. When CS develops clinical competence, it also supports staff self-efficacy and satisfaction. 17 This in turn reduces attrition which is better for the service. 4 Watkins (2020) indicated that CS was positively associated with managing workloads 8 which also contributes to improved patient flow through the system. 28
One of the challenges identified by this research was the definition of CS, particularly its boundaries with performance review and development, line management and professional progress. In this study, the definition of CS changed according to locality, clinical responsibility and level of seniority. The lack of clarity identified an ongoing barrier to CS in the clinical setting, or a ‘lost opportunity’. More consistent CS would be achieved with consistent approach, timing, documentation, language and structure of CS. This could be done by identifying a departmental CS champion. According to Snowdon (2019), it is the responsibility of the organisation to facilitate the CS and provide the training. 10
In summary, this study highlights that CS is beneficial for personal and professional development, and this in turn will support clinical services and retain staff. Health workforce managers are encouraged to facilitate training for both supervisees and supervisors. Advocating for choice of supervisor would encourage a strong interpersonal relationship to foster trust in the CS dyad.
Structured guided reflection would identify the objectives and outcomes of CS. Pre-planning CS sessions to include an agenda and supervisee goals would reduce stress related to the CS time in a busy clinical schedule. Simultaneously, a shared agenda to make roles and responsibilities explicit reiterates the relevance of CS within urgent clinical priorities. The provision of comprehensive, interactive training for supervisors that also develops reflexivity would support supervisors and supervisees in good CS practice. 24
Areas for future research include methods to capture frequency and content of the reactive, urgent supervision discussions. Further exploration of differences in perception of CS between professions would enhance understanding. Current online and face-to-face training should be evaluated for skill attainment, reflexivity and integration into clinical practice. Further research on patient outcomes related to CS would identify the translated effects. Any enhancement to clinical development would avoid the ‘lost opportunity’.
Limitations
This study has a major limitation with the over-representation of one discipline (Speech Pathology) and majority female participants. While the Australian Institute for Health and Welfare (2020) identifies female AH staff constituting 65.1% of the AH workforce, 29 the representation in this study was almost exclusive, providing no opportunity to investigate gender similarities and/or differences. Due to the deidentification within the focus groups, differences between disciplines was not explored and warrants further investigation. The bias of volunteer participants who were likely to be positively engaged with CS created additional limitations. The sites approved for participation were public hospitals in one metropolitan area and further research is required to investigate experiences for AH clinicians from private hospitals, mental health or rural services. Researcher bias was deliberated during research team discussions for data analyses and synthesis; however, remains a limitation in this qualitative study.
Recommendations
Managers to facilitate 1. supervisee and supervisor training 2. systems for self-assessment 3. explicit delineation of clinical supervision with professional development and line management 4. choice of supervisor
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Appendix
Focus group questions
Focus group questions approved by Ethics committee
Perceptions: • What is clinical supervision? o What does clinical supervision mean to you? o What do you get out of clinical supervision? o What are some of the benefits of clinical supervision? o What are some of the challenges of clinical supervision? • How does clinical supervision differ from line management? o How does it differ from professional development?
Processes: • If clinical supervision was done really well, how would you describe it? o what would it look like? o How might it differ to now? • Most of you have participated in clinical supervision in pairs – what would you think of group supervision? o What could be some of the benefits? o What could be some of the challenges? • How does reflection fit into clinical supervision? o How does it affect your clinical reasoning?
Impact: • Can you describe ways that clinical supervision affects your clinical practice? o In what way does it influence your patient care? o How does clinical supervision impact patient safety? o How does clinical supervision affect patient outcomes? o In what way does clinical supervision promote patient centred care?