Supervision of clinical work in mental health

Social Work

Supervision of Clinical Work in Mental Health

Mental health nurses along with other practitioners, often work in an ever changing and challenging environment. Because of this there is a continuing need for support. It is often thought that this support helps to increase morale, decrease strain and burnout, and encourage self-awareness and self-expression. Clinical supervision often addresses all these issues and improves the quality of care for patients (Rice, Cullen, McKenna, Kelly, Keeney and Richey, 2007).

Clinical Supervision is a competency-based approach that is often used to train and supervise mental health practitioners. For a long time supervision has been central to training psychologists and other mental health professionals who work in clinical settings. There was a time when there was little or no framework or guidance for those in this field (Falender and Shafranske, 2004). Clinical supervision in nursing has been described as a global phenomenon, however, it is a notion that lacks clear definition both in terms of its conceptualization and Operationalization. Despite the inconsistency in conceptualization, many experts have acknowledge that there are common threads that run through most definitions, in that it involves the provision of empathetic support to improve clinical skills and knowledge and foster a culture of reflective practice. Furthermore, this process takes place within a supportive environment in which the individuals are able to develop their own clinical practice and lend support to others (Cross, Moore and Ockerby, 2010).

Clinical supervision is a framework and a process whereby a clinical practitioner (supervisee) has the opportunity to meet regularly with an experienced colleague (supervisor) and discuss issues of relevance to their practice. It has been stated that patients and their families must be the beneficiaries of clinical supervision as it is after all a system to support and develop the professionals offering care to them. The principal factors relating to the need for clinical supervision in mental health nursing are:

1. The shift to community-based care for mentally ill people

2. increasing numbers of patients with complex illness and multiple diagnoses being admitted for assessment and treatment

3. introduction of clinical governance, placing the responsibility for the quality of care jointly on organizations and on individuals within organizations

4. increased emphasis on effectively managing risk the need to maintain registration through self-regulation activities (Rice, Cullen, McKenna, Kelly, Keeney and Richey, 2007).

It has been identified that there have been issues surrounding the definition of clinical supervision. Clinical supervision in mental health nursing: is a supervisee-led formal process where protected time is facilitated for professional support and learning; enables practitioners to develop knowledge, competence and skills required to provide best care; is ongoing bringing practitioners (supervisees) and skilled knowledgeable supervisors together in a supportive, environment; facilitates ongoing reflective practice and is a commitment throughout their professional career; is aimed at advancing clinical autonomy and self-esteem leading to personal and professional development. There are also countless clinical supervision models and many are relevant to mental health nursing practice. There is general acceptance that the models of clinical supervision should recognize the needs of specific groups. Some experts have suggested that clinical supervision is often underused because of misinterpretation, problems with organizational endorsement and supervisory relationships, and lack of funding or time (Rice, Cullen, McKenna, Kelly, Keeney and Richey, 2007).

In organizations where clinical supervision is measured, it is often found that staff scored lower on burnout and stress scores than in the control group of other organizations. It has not been possible to demonstrate that clinical supervision made any difference to patient outcomes. Clinical supervision is an inoculation against stress. It has been found that efficacious clinical supervision can make a contribution to supervisee well-being. The culture of the organization was crucial to the success of clinical supervision, and that effective supervisors are be rendered ineffective if they are not supported by their managers (Clinical supervision 'can inoculate staff against stress', 2010).

Supervision is necessary to counselor development both personally and professionally.

Supervision is triadic in nature, involving a supervisor, a supervisee, and a client. Within this relationship, the supervisor aims to foster and enhance the supervisee's professional development and competence as well as to ensure the client's welfare through the monitoring of the quality of professional services (Sangganjanavanich and Black, 2009).

Researchers have suggested that the supervisory relationship and working alliance between supervisees and supervisors is significant. A functional relationship is essential for certain knowledge to be conveyed from supervisors to supervisees. In the best of times, this relationship is intended to promote growth in supervisees and can be a source of trust, support, and understanding. In the worst of times, it can be a source of confusion, conflict, and misunderstanding. Conflict in supervision happens when the supervisor and supervisee are not able to communicate their needs and concerns to one another. Cross-cultural issues in supervision may occur when the supervisor, supervisee, and client differ in terms of ethnicity, language, age, gender, sexual orientation, socioeconomic status, spirituality belief, or willingness. Many studies have reported that multiculturalism or diversity in supervision is a potential issue influencing supervisory relationships (Sangganjanavanich and Black, 2009).

The counseling profession has recognized the importance of multicultural issues in training, however, there are few empirical studies focusing on this issue. In studies done in regards to multicultural supervision it has been found that supervisees and supervisors spent almost 15% of their supervision time addressing multicultural issues. Some participants have reported that it would have been beneficial for them if more time had been focused on multicultural issues in supervision. Miscommunications, misunderstandings, hidden agendas, assumptions, and disconnections between supervisors and supervisees seemed to occur when supervisors fail to initiate, explore, or discuss cultural issues in supervision (Sangganjanavanich and Black, 2009).

The power differential in supervisory relationships had the potential to impact the environment in which supervisees could address multicultural issues. Supervisees believed they were unable to voice their concerns. As a result, experiences and perspectives of supervisees regarding multicultural supervision were often unspoken and unheard. Supervisors who failed to integrate culture as a part of the supervision process were likely to experience frustration and resistance from their supervisees, and eventually the supervisees silenced themselves in supervision (Sangganjanavanich and Black, 2009).

Clinical supervision, within cooperative and supportive organizational cultures, has a creative potential to address difficult issues concerning non-aggressive yet assertive professional practice promoting good relationships with oneself and others. Subsequently, encouraging assertive yet reciprocal approaches to developing healthy working alliances in health-care settings seem possible. Even so, clinical supervision is in itself a complex undertaking, sometimes leading health-care professionals to contest with themselves and with the often harsh realities of the professional world in which they live and work. Potential exists to revisit emotionally troubling events arousing feelings of vulnerability, hurt, anger, guilt, shame, and in some situations, dependence on the supervisor. There is a need therefore for clinical supervisors to be alert to the dynamics of human service and to the potential for deleterious effects on health-care professionals. Supervised clinical practice has long held a centrality to psychological therapies and has evolved as an integral component of such services, offering support to practitioners and providing some measure of quality control. Nursing has sometimes struggled with coming to terms with supervised clinical practice, perhaps because in some instances, the term has been associated with failing and professional frailty Yet the notion that health-care professionals are recurrently strong and perpetually able to give of themselves while never needing support in return is an anachronism. In face of the demands of contemporary professional nursing practice, such ways of thinking make up powerful conventions. Nonetheless, because of feelings of insufficiency referred to earlier, they are unlikely to be successfully challenged without periods of personal conflict. However, if work discussions, which take place in clinical supervision, are supported and encouraged by organizations and are sensitively planned in ways that allows the restoration of emotional balance in health-care professionals, then the process learning elements of clinical supervision can provide experiences, which mobilize realistic hope for constructive professional practice. Fears might be reduced along with the better management of uncertainties aroused through providing health care (Jones, 2008).

It is the function of leadership to guide individuals and groups towards the goals and strategy of the organization and to assist, lead and support staff to achieve an optimal outcome from both an organization and employee perspective. As a result, leadership skills and the leader's well-being at work emerge as critical success factors. It is necessary for the leaders of an organization to attend to their own development on a continual basis. The leader's personal development requires evaluation of leadership activities and not just outcomes, operations and staff. The development of the leader's personal skills is a fundamental part of the development of the organization. The leader's personal qualities influence the way they lead people. It is usually not possible to examine and develop these qualities in knowledge-oriented management training. Other means of development are needed, such as administrative clinical supervision, where leaders can examine their leadership styles and become aware of their strengths and weaknesses. By improving their self knowledge, leaders can change and develop as leaders of people. Clinical supervision for leaders is sometimes called administrative clinical supervision. This is managerial clinical supervision with a focus on problems related to leadership and organization of work, particularly human relations issues. Administrative clinical supervision makes use of experiential learning focused on oneself and one's work (Sirola-Karvinen and Hyrkas, 2008).

Administrative clinical supervision means clinical supervision for leaders that address leadership issues in order to achieve set goals. Supervision promotes cohesion within the organization and is directed at change. Administrative clinical supervision is the examination of leadership in which leaders have the chance to reflect upon the quality of their decisions and share their feelings. In terms of action, administrative clinical supervision involves process-like support and mentoring, which boost the leader's confidence in coping with leadership duties and changes associated with it. Administrative clinical supervision addresses issues such as the development of the leaders work, the leaders ability to express feelings constructively, give and receive feedback, and create a work atmosphere that encourages expression of opinions and feelings (Sirola-Karvinen and Hyrkas, 2008).

It has just been recently that within the field of counseling and psychotherapy, clinical supervision has become accepted as its own specialty. It is no longer viewed as merely an expansion of the therapeutic process. Some licensing boards like those in Alabama and Louisiana have begun requiring clinicians to receive specialized training in clinical supervision before they can become supervisors. Even with extensive training and the best possible conditions, supervision is a challenging and sometimes daunting undertaking. One way to lessen the impact of the varying quality of supervision is through education of the supervisee (Pearson, 2004).

Formal supervision is essentially a mandated requirement since supervised counseling experience is required in order to obtain a degree and license. Many practicum students often find themselves asking to what degree they consider supervision to be an opportunity for learning, an inconvenience, a restriction, or an imposition. Reflecting on a number of attributes that supervisors expect from and find desirable in supervisees can facilitate this assessment of students' willingness to participate in and receive supervision (Pearson, 2004).

Although beginning students often have the misconception that supervisors just tell counselors what to do, supervisors are expected to function in a variety of roles depending on the needs of the supervisee. The roles that they often have to perform include teacher, counselor, and consultant. When taking on the role of teacher, the supervisor acts as the expert who provides answers and teaches the student in such areas as learning techniques, applying interventions, and conceptualizing. From the role of counselor, the supervisor facilitates the self-growth and explores the personal reactions of the trainee. The main focus of supervision interventions needs to be limited in order to help the function more effectively. In the consultant role, the supervisor provides options and alternatives rather than answers, and the interaction is friendlier. Instead of instructing and directing the student, the supervisor collaborates with the trainee in such areas as case conceptualization and treatment planning (Pearson, 2004).

Supervisor qualities of availability and approachability are critical components of effective supervision because the more comfortable students feel about approaching supervisors for help, the more likely they are to seek this help and get their needs met. Supervisors often have responsibilities like monitoring a student's work with clients, providing regular feedback to the student, offering suggestions for improvement, and limiting the relationship to supervision. Further expectations of effective supervisors include offering suggestions for dealing with specific therapeutic situations, providing practical support through modeling and coaching, giving emotional support through reassurance and encouragement, delivering feedback in a constructive way, and being proficient as a therapist (Pearson, 2004).

A sensible application of supervision theories can offer supervisors a useful guide for incorporating their own theoretical approaches and clinical knowledge into the supervision process. There are three levels of counselor development. Each of these levels finds counselor's exhibiting varying degrees of motivation, autonomy, and awareness. Knowing the developmental level of the counselor helps supervisors make decisions about the optimal supervision environment across several factors: (a) the balance of supportive vs. challenging interventions needed; (b) the degree of structure provided; (c) the amount of teaching, skill development, and direct suggestions needed; and (d) the degree to which counselors' personal reactions are explored (Pearson, 2001).

Figuring out the counselor's developmental level is the first step in choosing supervision strategies and shapes the foundation from which the other steps follow. While counseling experience is certainly a critical factor, assessing whether counselors fit in level one, two, or three depends on the degree to which they exhibit a stable motivation for being a counselor, an awareness of self and clients, and dependence on the supervisor vs. autonomous functioning (Pearson, 2001).

Level-one counselors, who are very uncertain about their counseling effectiveness, tend to be the following:

Highly anxious and highly motivated to learn

More focused on their own feelings and thoughts about what to do next in sessions and, subsequently, less aware of clients' needs and process dynamics

Highly dependent on the supervisor for direction, instruction, and support

Because of the intense anxiety, heightened motivation, and lessened awareness, level-one counselors need an environment with large amounts of support, direct instruction, and structure, and minimal amounts of challenge and personal exploration (Pearson, 2001).

Level-two counselors vacillate in their levels of confidence, anxiety, and motivation; struggle with feeling dependent and wanting autonomy; and improve in their awareness of clients' issues and relationship dynamics. Given the fluctuation in level-two counselors' confidence and wanting help vs. resisting help, the supervisor should generally reduce the amount of direct instruction and allow the counselor to influence the degree of structure needed (Pearson, 2001).

Supervision comes alive at the third level, with a challenging atmosphere, primarily in the form of self-challenge, and a deeper exploration of personal reactions and relationship processes because the counselors are much more consistent in their motivation, confidence, and skill level. At this level, the supervisor basically follows the counselor's lead in figuring out the content of supervision. Even though developmental levels change gradually over time, they are relatively consistent from session to session (Pearson, 2001).

Because of the similarities between counseling and supervision, supervisors often have to use their skills as counselors. But because of the important distinctions there is an added layers of complexity created for the supervisor to manage. The most obvious difference involves the focus and overall goals. In the counseling role, the principal focus is on the welfare of the client. In the supervisory function, the major goal is the professional growth and welfare of the counselor. But this goal still has to be balanced with the welfare and protection of the client. Having these dual objectives is often complementary to the degree that the counselor's improvement translates into better service for everyone including the clients. A conflict comes about when counselors' blind spots or ethical transgressions require supervisors to act in the best interest of the client, often at the expense of the counselors' independence and growth (Quinn, 2000).

Evaluation of the counselor by the supervisor is another thing that differentiates supervising from counseling. Supervisors have to regularly provide performance evaluations that have professional consequences for the counselor. There are a number of common issues related to evaluation including anxiety, power, discrepant evaluation, games, and conflict with other supervisory roles. In fact, in a study on the nature of nondisclosure by supervisees, impression management was one of the typical reasons cited for nondisclosures. Questions that surround the dynamics of the supervisory relationship must contain the potential impact of the evaluation (Quinn, 2000).

While an evaluation is often a source of threat to counselors, supervision often poses a threat to supervisors. That threat is the risk created by vicarious liability, a reality that can be unnerving when supervisors are held accountable for the counselor's behavior, especially when the supervisor has no way of knowing that the counselor behaved inappropriately. Supervisors have to be careful, not to let the need to reduce their anxiety turn the monitoring role into a policing one. This protective approach can often threatens the counselor and increases the danger by ensuring that counselors won't discuss their most challenging cases in which supervision is most needed (Quinn, 2000).

Managing the complex goals of client and counselor development within a supervisory relationship requires a level of trust that is often unmatched in the counseling relationship. Not only do counselors need to trust their supervisors, but supervisors need to trust the counselors being supervised. When trying to establish that trust, supervisors are faced with the delicate task of balancing supportive and challenging interventions. As such, supervisors need to provide a level of support and safety so that counselors feel comfortable enough to challenge themselves and to accept challenges from the supervisor. Such a trusting relationship helps to increase the protection of the client, the professional growth of the counselor, and the assurance to the supervisor that ethical concerns are being addressed (Quinn, 2000).

A discussion of the supervision process often leads to comparisons with the counseling process. There are many similarities that can be seen between the two processes, which allow counseling skills and techniques to translate well in supervision. Undeniably, the supervisory relationship is similar to the counseling relationship, and, therefore, relationship enhancement techniques such as empathy, immediacy, self-disclosure, confrontation, and respect which apply equally well in both contexts (Quinn, 2000).

While the similarities that exist between counseling and supervision often require supervisors to draw from their skills as counselors, there are important distinctions that create added layers of complexity for the supervisor to manage. One of the most obvious distinctions involves the focus and overall goals of supervision. Within the counseling relationship, the primary concern is the welfare and growth of the client. Likewise, in the supervisory relationship the professional growth and welfare of the counselor is a major objective. This objective, however, must always be balanced with the welfare and protection of the client. These dual objectives are often complementary to the degree that the counselor's improvement translates into better service for clients. A conflict arises, though, when counselors' blind spots or ethical transgressions require supervisors to act in the interest of the client sometimes at the expense of the counselors' autonomy and growth (Quinn, 2000).

Evaluation of the counselor by the supervisor is another factor that differentiates supervision from counseling. It is believed that supervisors heighten the threat of the evaluation process by denying its centrality to the supervision process. Both counselors and supervisors must deal with the reality that supervisors provide explicit performance evaluations that have professional consequences for the counselor. In a study on the nature of nondisclosure by supervisees, impression management was one of the typical reasons cited for nondisclosures. Thus, questions about the dynamics of the supervisory relationship must include the potential impact of evaluation (Quinn, 2000).

Clinical supervision is 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. It has been suggested that supervision is widely discussed as a means of helping people to avoid burnout and job-related stress and improve clinical performance (Edwards, Burnard, Hannigan, Cooper, Adams, Juggessur, Fothergil and Coyle, 2006).

Clinical supervision is the process of control and direction of a recipient's mental health services by which a mental health professional provider:

Accepts full professional responsibility for the supervisee's actions and decisions

Instructs the supervisee in their work

Oversees/directs their work

There is more than one mental health clinical supervision standard. Mental health providers must meet the following conditions:

Be present and available on the premises more than 50% of the time in a five working day period during which the supervisee is providing a mental health service

The diagnosis and the recipient's ITP/a change in the diagnosis/ITP must be made by or reviewed, approved, and signed by the provider

Every 30 days, the supervisor must review and sign the recipient's record of care for all activities in the prior 30-day period (Mental Health Practitioners General Clinical Supervision Requirements, 2010).

There are different models of clinical supervision that reflect the differing professional training and expectations, work contexts and needs of staff. When determining the supervision model to be implemented by the mental health service, consideration should be given to the experience and knowledge of the supervisee, the supervisor's preference or style of working, the needs of the supervisee and the context of work. It is anticipated that there will be different models of supervision operating within a mental health service, therefore it is essential that the supervisee and the supervisor or supervisory group discuss the parameters of the supervision relationship (Clinical Supervision Guidelines, 2005).

Within any good working relationship the effective process of communication and interaction is an essential ingredient. In a clinical supervision relationship, whether it is between two individuals or a group of people, communication and interaction provides the essential framework for the professional relationship to develop. It helps build up trust and rapport, and it provides an articulate process that is empowering, supportive and, when necessary, directive. One of the principle barriers within a clinical supervisory relationship is the presence of 'professional power'. Power inequalities arise within supervisor and supervisee relationships, and between majority ethnic groups and minority ethnic groups. Trans-cultural clinical supervision is concerned with the process of supervision between practitioners who have different cultural and ethnic backgrounds (Nadirshaw and Torry, 2009).

Promotion into supervision can no longer be based on clinical skills. The clinician, regardless of level of education, credentials, field, populations served or work experience, must develop a separate set of skills and knowledge base to become a competent and effective supervisor who can handle a myriad of ethical, clinical and supervisee situations. The instructor will offer guidance to build or enhance supervision skills and strengthen critical judgment and relationship skills. Through concepts taught in this seminar, participants will be able to more effectively do their job and become comfortable in the role of a clinical supervisor (Sangganjanavanich and Black, 2009).

Clinical supervision offers a framework that encourages review and reflection in practice. If properly implemented, clinical supervision will be the greatest driver in taking forward excellence in care. Clinical supervision must have commitment from all levels in the organization, from practitioner through to Chief Executive. It requires time, funding, manpower and training. As recognized by many nursing experts who have written widely on the subject, clinical supervision, in the near future needs to be embedded in pre-registration nurse education and facilitated in clinical practice where the continuum of clinical supervision really begins. In this way, clinical supervision will be expected, as a continuum of lifelong learning (Clinical Supervision for Mental Health Nurses in Northern Ireland: Best Practice Guidelines, 2004).

Clinical supervision refers to a formal, structured process of professional support, learning and reflective practice. It assists with:

understanding issues associated with practice developing new insights and perspectives improving knowledge, skills and competence enhancing support for staff while improving consumer and career outcome professional accountability and autonomy.

Clinical supervision may be conducted individually or in small groups. The process of clinical supervision is different from line management/administrative supervision, where the former emphasizes professional development and support and the latter monitors work performance associated with organizational goals (Clinical Supervision, 2009).