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CLINICAL

SUPERVISION

HANDBOOK

A GUIDE FOR CLINICAL SUPERVISORS

FOR ADDICTION AND MENTAL HEALTH

The Office of Nursing Practice and Professional Services

(Centre for Addition and Mental Health) and

the Faculty of Social Work (University of Toronto)


CLINICAL

SUPERVISION

HANDBOOK

A GUIDE FOR CLINICAL SUPERVISORS

FOR ADDICTION AND MENTAL HEALTH


CLINICAL

SUPERVISION

HANDBOOK

A GUIDE FOR CLINICAL SUPERVISORS

FOR ADDICTION AND MENTAL HEALTH

The Office of Nursing Practice and Professional Services

(Centre for Addiction and Mental Health) and

the Faculty of Social Work (University of Toronto):

Kirstin Bindseil

Marion Bogo

Tim Godden

Marilyn Herie

Eva Ingber

A Pan American Health Organization /

World Health Organization Collaborating Centre

Regine King Kathy Ryan

Kate Kitchen Rani Srivastava

Jane Paterson Lea Tufford

Maria Reyes

Cheryl Rolin-Gilman


ISBN: 978-0-88868-725-8 (PRINT)

ISBN: 978-0-88868-726-5 (PDF)

ISBN: 978-0-88868-727-2 (HTML)

Product code PG121

Printed in Canada

Copyright © 2008 Centre for Addiction and Mental Health

Any or all parts of this publication may be reproduced or copied with acknowledgement,

without permission of the publisher. However, this publication may not be reproduced

and distributed for a fee without the specific, written authorization of the publisher.

This publication may be available in other formats. For information about

alternative formats or other camh publications, or to place an order, please contact

Sales and Distribution:

Toll-free: 1-800 661-1111

Toronto: 416 595-6059

E-mail: publications@camh.net

Website: www.camh.net

This book was produced by the following camh staff:

Editorial: Diana Ballon, Jacquelyn Waller-Vintar

Design: Nancy Leung

Print production: Christine Harris

3542/03-2008 PG121

Clinical Supervision Handbook


Contents

v Contents

ix Introduction

ix Development of the Handbook

ix Perspectives on Clinical Supervision

x Literature Review

x Framework for Clinical Supervision

1 CONTEXT OF CLINICAL SUPERVISION

1 Models of clinical supervision

Social Work

Nursing

Common Elements

Components of Clinical Supervision Models

3 Clinical Supervision at camh

Practice Environment

Leadership

Clinical Supervision Principles

9 Components of Clinical Supervision

Roles

Supervisory Activities

11 Clinician Development

12 Supervisor Development

13 Clinical Supervision, Knowledge Translation and Evidence-Based Practice

Incorporating Evidence-Based Practice into Clinical Supervision

17 Cultural Competence and Clinical Supervision

Cultural Competence

Incorporating Cultural Competence into Clinical Supervision Practices

23 IMPLEMENTING CLINICAL SUPERVISION

23 Beginning Clinical Supervision

The Clinical Supervision Relationship and Contracting

When Clinical Supervision is at the Request of the Manager

Giving Feedback on Performance

Learning Styles

Learning Styles and Clinical Supervision

v


Clinical Supervision Handbook

37 Ongoing Clinical Supervision

Methods Of Clinical Supervision

Cultural Competence and Diversity

Group Supervision

Individual Clinical Supervision

A Case Presentation Model for Clinical Supervision

Spontaneous Clinical Supervision: Clinical Supervisor as Lighthouse

71 SPECIAL ISSUES

71 Interdisciplinary Clinical Supervision

Strengths of the Clinical Staff

Staff Cultural Diversity and its Impact on Clinical Supervision

Context of Interdisciplinary Supervision

Interdisciplinary Supervision in Practice

75 Nursing and Clinical Supervision

Reflective Practice

Exploring Nurse’s Perceptions of Clinical Supervision

Practical Issues

Preparation

78 A Multi-Method Professional Development Approach in Daily Practice

Integrated Care and Building Capacity in the Schizophrenia Program

82 Ethical Considerations in Clinical Supervision

Standard of Care

Ethical Considerations: An Example

85 Evaluating Clinical Supervision

86 Core Competencies in Clinical Supervision

Benefits and Barriers to Effective Clinical Supervision

Evaluating Diversity Competence in Clinical Supervision

Clinical Supervisor Evaluation

Documentation of Supervision In Clinical Settings

103 APPENDIX 1

103 Conceptualization of Clinical Supervision: A Review of the Literature

Social Work

Nursing

Conclusion

vi


115 APPENDIX 2

115 Evalautions For a Clinical Supervision Group

PART A

PART B

117 APPENDIX 3

117 Clinical Supervision Contract

119 APPENDIX 4

Contents

119 Core Clinical Practice Competencies

Levels of Practice

Domains of Practice

vii


Introduction

This handbook is the result of a group of advanced practice nurses and clinicians

who function as clinical supervisors at the Centre for Addiction and Mental Health

(camh) using their collective experiences to articulate a model of clinical supervision

in this organization. It reflects the integration of clinical experience, practice

wisdom and contributions from contemporary literature and research. The literature

and research base informing this handbook is drawn primarily from the social work

and nursing fields, with some references to psychology and organizational change. A

comprehensive review and integration of the supervision literature from all allied

health disciplines is beyond the scope of this handbook; however, we hope that readers

from all disciplines will find relevant and practical tips and suggestions.

DEVELOPMENT OF THE HANDBOOK

We used a range of iterative and developmental activities to create the handbook.

Initially there was considerable reflection and discussion about the nature of clinical

supervision, the activities and processes that appeared to work, and the challenges

faced. Individuals or small groups volunteered to develop topics further.

Conceptual, practice and empirical literature about clinical supervision was reviewed

from the perspectives of social work, nursing, psychology and other relevant sources.

Further discussion of the material led to refinement of ideas and practices. The discussion

also revealed confusion and tension about the definition of clinical supervision

within an organization and about developing effective supervision practices.

PERSPECTIVES ON CLINICAL SUPERVISION

The development of the handbook was an inter-professional practice activity that

brought together a team of experienced social workers and nurses. The members of

the team share:

• a commitment to client-centred care

• a commitment to professional education and development

• a common vision as employees of camh.

Professions have their own distinct cultures, histories and practices. Terms such as

ix


Clinical Supervision Handbook

“supervision” therefore have different meanings for nurses than they do for social

workers. As the working group explored clinical supervision, it became apparent

that this concept and function is interrelated with ideas about:

• power, authority, accountability and autonomy of individuals, managers and

clinical supervisors

• decision making in groups and teams

• the perceived organizational conditions necessary for education and professional

development.

LITERATURE REVIEW

The review of the literature presents the diverse way these themes are conceptualized

and the similarities and differences between professions (see Appendix 1, p. xx). Even

within professions there are different models of clinical supervision with varying

emphasis on accountability, reflection, applying theory to practice, coaching and skill

development, and integration of evidence-based practice. Through dialogue, it also

became evident that individuals have different perspectives about the complex issues

related to clinical supervision based on their own educational and work experiences.

The handbook therefore merges concepts from diverse clinical disciplines, particularly

nursing and social work, to develop an approach to clinical supervision that respects and

builds on these traditions while providing guidance for the challenges of supervision

and practice in mental health and addiction in contemporary society.

FRAMEWORK FOR CLINICAL SUPERVISION

The framework for supervision (see p. xx) represents current conceptualizations and

can provide principles to guide the process of clinical supervision through its various

stages. The goal is to enhance the knowledge of our clinical supervisory staff and

delineate the standards of clinical supervision we provide at camh. Three interrelated

functions of clinical supervision identified in both the nursing and social literature

are discussed: administrative, educational and supportive (Kadushin, 1976; Kadushin

& Harkness, 2002; Proctor, 1986). Methods and competencies for supervisors are presented

along with a suggested evaluation method. Special issues in mental health and

inter-professional settings are also examined.

Since camh is a major teaching centre, it is important to note that the practice of

clinical supervision of staff is distinct from supervision of students. Clinical supervision

x


Introduction

can involve complicated organizational dynamics, hierarchies of administrative

authority and multiple accountabilities (Tsui, 2005). Anyone who provides clinical

supervision must be skilled in these practices. In Clinical Supervision, we discuss the

ways in which a psychologically safe environment can be created so that complex

clinical dilemmas can be brought forward. We also examine the clinical supervisor’s

ability to provide clear and meaningful feedback and outline the parameters of clinical

supervision.

This handbook is a “work-in-progress” that will be expanded and further refined

over time. We will continue to address the challenges outlined above through further

consultation with clinical staff and colleagues in similar organizations. We welcome

your comments and suggestions.

xi


CONTEXT OF

CLINICAL SUPERVISION

Models of clinical supervision

The definition of supervision differs across settings and professions.

SOCIAL WORK

Social work literature reflects a long history of valuing clinical supervision as the

crucial vehicle for professional development of the social worker (see Appendix 1,

Conceptualization of clinical supervision: a review of the literature, p. 103). Supervision

in social work is essentially conceived as a method to ensure the organization’s

mandate is achieved through enhancing the supervisee’s*ability to provide effective

service. Through discussion of routine and complex clinical situations, clinicians are

better equipped to meet client needs, and that, in turn, contributes to improved

client outcomes.

NURSING

In the nursing literature there is less agreement on the definition of clinical supervision

(see Appendix 1, Conceptualization of Clinical Supervision: A Review of the Literature,

p. 107). Logistical realities of nursing—including time away from clients, rotating

shifts, 24-hour care and stringent time-oriented duties make the use of clinical

supervision challenging. It appears from this literature that clinical supervision

has often been viewed as an authoritarian and hierarchical activity that arises in

response to an error or indiscretion.

This is beginning to change. Jones (2005) reviewed research literature on clinical

supervision and credits Winstanley and White (2003) with the most comprehensive

1


definition: “[clinical supervision focuses] upon the provision of empathetic support

to improve therapeutic skills, the transmission of knowledge and the facilitation of

reflective practice. The participants have an opportunity to evaluate, reflect, and develop

their own clinical practice and provide a support system to one another” (p. 8).

COMMON ELEMENTS

A comparison of the social work and nursing literature on clinical supervision

reveals common elements in the approaches offered by Kadushin’s model of three

interrelated functions of social work supervision and one model in nursing, Proctor’s

three function-interactive model (see Appendix 1, p. 103). Both nursing and social

work agree that clinical supervision should be differentiated from, on one hand, an

exclusive focus on line management, and, on the other, a quasi-therapeutic approach,

although elements of each may be present at times in the process of supervision.

COMPONENTS OF CLINICAL SUPERVISION MODELS

Administrative/normative (managerial)

Kadushin uses the term administrative supervision to describe selecting and orienting

workers/clinicians, assigning cases, monitoring, reviewing and evaluating work;

serving as socializing agent; and advocating and buffering within the organization.

Proctor uses the terms normative or managerial to describe a function that promotes

and complies with organizational policies.

Educational/formative

Clinical Supervision Handbook

Both professions’ models have an educational component. For Kadushin, education

encompasses activities that develop the professional capacity of supervisees, including

teaching knowledge and skills, and developing self-awareness (Barker, 1995;

Munson, 2002) through, for example, teaching, case consultation, facilitating learning

and growth. For Proctor, educational supervision addresses skill development

for evidence-based nursing practice.

2


Supportive/restorative

Clinical Supervision at camh

Kadushin’s third component is supportive supervision. He sees this component as

helping workers to handle job-related stress by providing appropriate praise and

encouragement, normalizing work-related reactions, affirming strengths, and sharing

responsibility for difficult decisions. Proctor’s third component, restorative (also

referred to as pastoral), is similar. It is a support function that helps the nursing

practitioner to understand and manage the emotional stress of nursing practice.

Each of these components is seen as influencing each other and as producing more

effective services for clients when operating in concert.

Clinical Supervision at camh

At camh, we are committed to upholding the highest standards of clinical care and

practice and to supporting the best clinical practice, professional education and professional

development for our staff. We strive to be a workplace where people excel

in a culture that embraces diversity and encourages teamwork, quality improvement,

safety and respect. We have a rich inter-professional environment at camh with

approximately 1,500 clinical staff representing 16 professional disciplines. It is essential

that these clinicians be supported in the work they do and that they receive the

organizational support required for ongoing professional growth and development.

Clinical supervision has been identified as one of the most important factors in

determining job satisfaction and quality of service to clients (Tsui, 2005). We therefore

believe that it is important to establish standards for clinical supervision

practice. We also realize the vital role that clinical supervision plays in supporting

clinicians in adapting to change. Initiatives such as Concurrent Disorders Capacity

Building, Clinical Cultural Competence, Building a Culture of Safety, Family

Centred Care, and Implementing a Recovery Framework are examples of broadbased

initiatives at camh that are supported by clinicians. Front-line clinicians are

vital to the successful implementation of these initiatives and when operational

challenges are encountered, clinical supervision plays a crucial support role.

3


PRACTICE ENVIRONMENT

The practice environment must include multiple perspectives and interests.

Individual clinicians are accountable to clients, colleagues, organizations and regulatory

bodies. Organizations must ensure standards and delivery of high quality care.

External stakeholders may influence practice with advice on models of practice that

should be emphasized. Funders link resources to outcomes, and consumer and family

groups are now active partners in program planning and service delivery. As an

organization, we must acknowledge and accept differing—and at times opposing—

positions on issues related to practice. For instance, at times legal advice may in fact

differ from the practice advice from a regulatory body. It is our task to create a practice

environment that allows for the expression of divergent opinions with the goal of

resolving issues. Clinical practice dilemmas and errors are a fact of life; it is the

response that counts. A culture of blame, over-regulation and punitive responses

will deter disclosure. Opportunities to identify the underlying conditions that led

to those clinical dilemmas and errors will be lost unless processes for review and

reflection are established to allow disclosure and discussion of difficult issues. Thus

clinical supervision has a dual focus: clinician development; and improved care and

enhanced health for our clients.

At camh, the desired practice environment includes:

• clinicians practicing ongoing critical self-appraisal

• an openness to the opinions and input of the client, and the work of the clinical

supervisor

• honest communication

• clear and regular documentation

Clinical Supervision Handbook

• clinical practice that actively explores, examines and contributes to the evidencebase

for care and support

• an acknowledgement of the complexities of clinical practice

• empowerment of clients, families and communities

• active and ongoing dialogue among employees at all levels.

The process of clinical supervision is integral to the realization of these goals.

4


LEADERSHIP

The clinical discipline chiefs, the advanced practice group and the clinical leadership

in the program areas have primary responsibility for development of professional

knowledge and skills. The discipline chiefs and the advanced practice group are in

many ways more similar than different in the roles and functions they perform in

the organization. The roles of both groups comprise five interrelated domains:

• practice

• consultation

• education

• research and scholarship

• leadership.

Perhaps the greatest difference between the two groups is that the discipline chiefs

are senior clinicians who lead the entire professional discipline across the organization

and are responsible for ensuring that professional practice standards are

adhered to across camh. The Advanced Practice Nurses or Clinicians (apn/c), also

senior clinicians, work directly in the clinical programs and supervise clinicians

from various disciplines. Members of the discipline chiefs, program clinical leadership

and the advanced practice groups can all have a role in the clinical supervision

of staff. It is important that those responsible for front-line staff be skilled in the area

of clinical supervision in order that job achievement be recognized and acknowledged.

CLINICAL SUPERVISION PRINCIPLES

Clinical supervision at camh is guided by the following interrelated principles:

• organization context and its crucial impact on the nature and quality of clinical

supervision

• improved client outcomes

• accountability

Clinical Supervision at camh

• advancement of clinicians’ specialized knowledge, skill and use of evidence-based

practice

• learning and professional development.

These principles support the organization’s goals of improved client-centred

5


care; enhanced health and client safety; and support, growth and retention of the

best professional staff.

Organizational context

Clinical supervision occurs within the organizational context and will be customized

in response to the unique characteristics of a particular clinical program area.

Organizations that value and promote clinical supervision as both an educational

process for clinicians and as a way to enhance accountability achieve greater employee

satisfaction and improved client outcomes.

Two overarching organizational themes characterize camh: a unionized environment

and clientele divided between inpatient and outpatient services. The hierarchical

environment of a unionized setting places the responsibility for clinical supervision

on those at the managerial level. All clinicians require high-quality clinical supervision

to meet their challenges and need for ongoing support. As an organization,

it is important that we find ways to provide clinical supervision to staff that work

shifts in the inpatient and residential areas at times when managers and clinical

supervisors may not be readily available to provide consultation.

When two or more hospitals merge to form a new organization, the organizational

culture often differs from that of its founding organizations. This may affect the

availability, perception and experience of clinical supervision. It takes time to develop

a shared perspective on the nature and process of clinical supervision. Any organization

comprises many departments, disciplines and individuals with a range of working

styles that contribute to its overall rhythm and achievements. Clinical supervision

requirements will vary with the unique program, culture, team members and learning

styles of its participants and so must be tailored accordingly. For example, when

camh was formed, there wasn’t a consistent practice of clinical supervision across

the entire organization. Although it was agreed that clinical supervision is integral to

clinical practice, it was necessary to redefine clinical supervision in this new culture.

Improved client outcomes

Clinical Supervision Handbook

One of the aims of clinical supervision is the improvement of client outcomes. Given

the breadth of service at camh outcomes are not the same for all clients but fluctuate

to accommodate client needs and challenges. Increasingly, we experience greater

complexity in the client populations we treat.

6


Accountability

The supervisory relationship entails accountability within a supportive and educational

framework. By virtue of their role in the organization, clinical supervisors,

along with the staff they supervise, have accountability for client outcomes. Also, the

clinical supervisor is responsible for monitoring the clinical performance of staff.

The accountability demands on health care organizations are generally steep and the

clinical supervisor needs to account for client and worker outcomes. It is challenging

for the supervisor to balance the two functions of support and accountability. People

engaged in clinical supervision need to discuss this duality from the outset. It also

challenges more traditional notions of clinical supervision, where a clinician would

be assured of almost complete confidentiality in processing cases with the clinical

supervisor.

Specialized knowledge, skill and use

of evidence-based practice

The following summarizes the generic competency required of all camh clinical staff

regardless of professional discipline:

• clinician-client relationship

• family and social support

• professional autonomy and accountability

• professional development and research

• assessment and monitoring

• interviewing, formulation and documentation

• treatment planning

• therapeutic interventions

• anticipating and responding to rapidly changing clinical situations

• evaluation of care

• teaching, coaching and empowering

• teamwork, collaboration and partnerships

• ethical, organizational and legal accountabilities

• consultation and education

Clinical Supervision at camh

7


For a description of the requirements for each of these domains, see Appendix 4,

p. 119.

As well as generic competencies, all clinicians are expected to have specialized

knowledge and clinical skills associated with the clinician’s program.

Professional development

Clinical Supervision Handbook

Professional development within one’s discipline flows from a commitment to lifelong

learning: clinical supervision is one method for achieving this goal. Regulated

health professionals are members of regulatory bodies with annual educational

requirements and standards of practice and ethical conduct. Unregulated clinicians

who are members of professional associations often must meet educational objectives

to qualify for, and maintain, membership. Clinical supervision can help clinicians

stay abreast of developments in their field.

Educational and clinical supervisory opportunities may be provided in ones’ place

of employment. Many professionals participate in external educational activities such

as courses, workshops or private consultation. In organizationally offered clinical

supervision, clinicians demonstrate their commitment to ongoing learning and show

accountability to the process through their willingness to learn, their interest in

developing their clinical skills and being open to receiving support and being challenged.

Through the formation of a partnership for learning, clinical supervisors

and clinicians agree to journey together toward both the development of clinicians

as learners and as members of their colleges.

8


Components of Clinical Supervision

ROLES

Clinician

Components of Clinical Supervision

In clinical supervision, clinicians can achieve a higher level of expertise in their

discipline and/or specialized area of practice. A hallmark of clinical supervision is

the opportunity to reflect on one’s own practice, to gain others’ opinions and hence

develop a more accurate self-appraisal and, through discussion, to draw the links

between theory and practice.

Clinical supervisors and clinicians work together to develop and maintain productive,

goal-oriented supervision. They negotiate the framework in which clinical supervision

is carried out, including establishing the frequency of meetings, avoiding outside

interference and being prompt. Clinicians define their own learning goals. The goals

often arise from the case examples they select. These goals can be met through learning

from supervision and from activities clinicians undertake beyond the supervisory

session. Clinicians prepare for clinical supervision by having an agenda and information

pertinent to the case or to clinical dilemmas. Information can include case notes,

segments of tapes, a care plan and case questions. Case material should represent

challenges and difficulties as well as successes. By choosing to discuss cases where they

have encountered difficulties, clinicians demonstrate their willingness to take risks

and learn from others. The learning process involves dialogue, openness to in-depth

reflection on practice, and receiving both challenging and supportive feedback. The

clinician records the supervisor’s recommendations and the actions or outcomes he

or she has taken as a result of clinical supervision in the outpatients’ progress notes

and in the interdisciplinary plan of inpatients.

Clinicians are active participants in clinical supervision and give feedback to the

supervisor so they can jointly evaluate the process in relation to the verbal or written

supervision contract. Contracting at regular intervals allows the clinician to discuss

learning goals, and the clinical supervision process, and to adjust the contract as

necessary. It is the responsibility of the clinician to apply what he or she has learnt

with clients. Self-evaluation is imperative and allows clinicians to determine when

learning goals are met and when the clinician is ready for a more active or autonomous

role with clients, such as in leading a group.

9


Learning is not relegated to the confines of the supervision session. The clinician

and clinical supervisor, working together, must negotiate and agree on the expectations

for learning between sessions. Activities may include reading, viewing videos

and writing process recordings or detailed notes of sessions.

Clinical supervisor

Clinical supervisors demonstrate substantive or content knowledge in multiple

domains through discussion of clinical issues, examination of organizational development

and inter-professional practice. The ability to work with the content of

multiple domains engenders confidence in supervisory skills. Clinical supervisors’

credibility, based on formal education and depth of experience, is an important

contributor to the supervisor-clinician relationship. Another factor is the availability

of clinical supervisors for both scheduled and unscheduled supervision, since concerns

related to clients also arise beyond the usual hours of the working day. Good

clinical supervisors recognize and value diverse perspectives. They also acknowledge

the clinician’s previous work experiences. These factors contribute to a rich, heterogeneous

work environment.

Shared responsibility

Clinical Supervision Handbook

The supervisor and the clinician share responsibility for creating a safe environment

for clinical supervision. Safe environments are characterized by respect, openness,

support, trust and the provision of non-judgmental feedback. The establishment

of a safe environment allows creativity to flourish when dealing with challenging

situations and expands the possibilities of service delivery.

Power and authority

The hierarchical aspect of the supervisor-clinician relationship can lead to conflict,

stress and tension. Effective clinical supervisors don’t ignore the inevitable power

dynamics. Instead they model a parallel process of journeying together. Supervision

experts note as crucial the ability to exercise supervisory responsibility in a respectful,

fair and objective manner and to purposefully avoid the abuse of power (Centre

for Substance Abuse Treatment, 2007).

10


SUPERVISORY ACTIVITIES

Clinician Development

Clinicians come to clinical supervision with a diverse array of learning styles, such

that the adage “one size fits all” doesn’t apply. Recognizing and then adapting

teaching to match the learning styles of clinicians is a critical supervisory skill

(see Learning styles, p. 33). Observation, discussion, feedback, role play, coaching,

demonstrating and questioning are examples of supervisory activities. Supervisors

need to master each of these so they can customize learning activities to meet the

needs of all the clinicians with whom they are working.

Conceptual frameworks that link theory to practice that’s relevant to camh clients

help clinicians’ work to progress in an intentional and planned manner. Reflection

encourages and provides the opportunity for clinicians to consider their experiences

in practice, explore feelings invoked through working with clients, and understand

the meanings they give to interactions. This process allows clinicians to arrive at

more mindful and deliberate subsequent interventions. Critical self-reflection and

self-inquiry helps clinicians recognize their strength and growth areas.

Clinician Development

Clinicians pass through stages in their careers. In the early stages of their careers, or

when they join a new organization, clinicians may benefit from increased support,

education and clinical supervision as they orient themselves to the organizational

environment and clientele. Later career professionals may require less clinical supervision

and more focused case consultation.

Most professionals are educated in their specific disciplines, and while in training

may have little opportunity to collaborate with other disciplines. However, in health

care organizations, they are expected to participate in teamwork and collaborative

practice. There is an increasing number of inter-professional education initiatives

that recognize the knowledge base required to practice collaboratively. The curricula

of the health care disciplines are evolving so that students will have the opportunity

for curriculum and practicum experiences in collaborative practice.

11


Clinical Supervision Handbook

The optimization of holistic clinical care first requires clinicians to be well grounded

in their own professional discipline. It is a challenge for a junior clinician to maintain

this professional identity and assert the unique perspective of the discipline within

the interdisciplinary team. Without the opportunity for regular clinical supervision

and reflection on their unique roles in teams, junior clinicians can risk aligning

themselves with the power base on a team, thus silencing the unique perspective of

their discipline. The clinical supervisor therefore must consider the career stage of the

clinician in choosing pertinent material and issues for supervisory sessions.

Supervisor Development

Clinical supervisors, similar to clinicians, engage in professional development in

their various roles. Reflection on their practice as clinicians and as supervisors allows

them the opportunity to examine themselves from cognitive, affective and behavioural

angles. By acknowledging strength areas and challenging inherent assumptions

and ineffective patterns, clinical supervisors deepen their level of service offered to

both clients and clinicians and are able to seek their own supervision as required.

Professional development may also result in further expertise in a clinical issue or

exploration of a new area. Clinical supervisors are in an excellent position to provide

leadership with respect to evidence-based practice through staying abreast of the

most current literature and introducing new concepts, practices and guidelines in

their supervisory meetings with clinicians. Continuous learning refreshes clinical

processes, allows clinical supervisors to remain current and promotes a similar

commitment on the part of clinicians.

The processes of transference and countertransference are two of the inevitable

by-products of working in helping professions. Effective clinical supervisors understand

the dynamics of these two processes both between client and clinician and

between clinician and clinical supervisor. Clinical supervisors facilitate clinicians’

understanding of how these dynamics impact on clinical work. At the same time,

clinical supervisors reflect on their personal transference and countertransference

issues to promote their development.

12


Clinical Supervision, Knowledge Translation and Evidence-Based Practice

Clinical Supervision,

Knowledge Translation

and Evidence-Based Practice

Organizations of all sizes are increasingly concerned that clinical practice be based

on research where possible. The rise of “best practice” documents and guidelines

attests to the urgency of bridging the gap between research and practice and reflects

the reality that most clinicians do not read—let alone incorporate—scientific findings

and practice protocol. Funders, consumer groups, researchers and agency/program

management have all identified “knowledge translation” as a major challenge.

Knowledge translation has been defined by the Canadian Institutes of Health Research

(cihr) as “the exchange, synthesis and ethically-sound application of research findings

within a complex system of relationships among researchers and users.” There is a

growing body of literature on the topic of knowledge translation relevant to health

care. The notion that clinical decisions should be made based on evidence-based

practices and systematic review has become widely accepted (Zwarenstein & Reeves,

2006). It is also well recognized that the results of research are unevenly adopted in

clinical practice (Haines, 1998). The process of translation does not happen on an

immediate or consistent basis because of the varying characteristics of adopters

(i.e., practitioners). For example, Rogers (1983) suggests that innovations are picked

up first by innovators and early adopters—the “champions” of practice innovations—

followed by the early majority, the late majority and the small group of late adopters

or “laggards.” In recognition of the challenges of transferring and adapting research

findings to clinical practice, attention has been focused on understanding factors

affecting the transfer of knowledge.

Reviews of knowledge transfer literature have suggested that the failure of collaboration

and communication between health care professionals has a profoundly negative

effect within the health care system (Kerner et al., 2005; Zwarenstein & Reeves, 2006).

To address this issue, it is important to design a clinical supervision process that

accommodates the needs of the many professions and disciplines in the health care

system, and to develop good inter-professional collaboration.

One of the most common strategies in enhancing or incorporating evidence-based

practice has been through clinically focused, continuing education workshops.

13


Clinical Supervision Handbook

However, research has shown that clinical practice is minimally influenced by training

alone (see Miller et al., 2006 for a review of this research.) In fact, Miller et al. (2006)

point out that “[s]elf-reports of competence . ..bear little or no relationship to

actual behavioural proficiency in delivering a treatment” (p. 32). On the other hand,

there is some evidence that clinical training combined with ongoing feedback and

coaching (such as that provided through supervision) can yield significant improvement

(Miller et al., 2006).

Clinical supervision is, therefore, critical for promoting the use of evidence-based

models and tools, as well as an effective means of disseminating these approaches.

As Miller and colleagues (2006) state, “The dissemination of knowledge-focused

material and workshops cannot substitute for proper clinical training, feedback and

supervision in helping providers learn more effective ebt [Evidence-Based Treatments]”

(p.35, emphasis added). Given the importance of offering—and having clinicians

adhere to—evidence-based treatment models, knowledge translation should be a

major focus of clinical supervisors’ work.

INCORPORATING EVIDENCE-BASED

PRACTICE INTO CLINICAL SUPERVISION

Ongoing feedback and coaching are critical in helping clinicians to implement

evidence-based practice applications and treatment protocols. Clinical supervision

is an obvious and ideal context for this to occur. A number of important elements

are prerequisites:

Clinical supervisors and clinicians understand and are committed to evidencebased

practice approaches.

• The clinical supervisor has expertise in the evidence-based methods in which

clinicians are practising.

• There are opportunities for observation and practice of clinicians’ clinical

interactions during supervision sessions.

Clinical supervisors provide corrective feedback that is experienced by clinicians

as constructive, relevant and credible.

14


Clinical Supervision, Knowledge Translation and Evidence-Based Practice

Commitment to evidence-based practice

The implementation of evidence-based approaches is not without controversy

among human service practitioners, and has been criticized on the grounds that

it privileges empiricism over other dimensions and sources of wisdom, such as

qualitative research, practice wisdom, consumer perspectives, cultural considerations

and situational context (Petr & Walter, 2005). This perspective, however, doesn’t

acknowledge the ways in which our understanding of evidence-based practice has

evolved. For example, Petr and Walter discuss how, in the social work field, the

rise of empirically based practice in the late 1980s emphasized clinical practice

based primarily on scientific expertise. By the mid-1990s this notion broadened

to consider the appropriateness of research applications to individual situations,

ethical issues, and client values and expectations. Current conceptualizations refer

to “evidence-based practice wisdom,” with an appreciation of multiple sources

of “evidence” applied in a value-critical approach. It may be necessary for clinical

supervisors to discuss clinicians’ understanding of evidence-based practice, and

to explore how clinicians apply advances in scientific knowledge and integrate

these with other knowledge sources.

Supervisor expertise

In the supervision context, “expertise” means more than one’s ability to demonstrate

advanced proficiency in evidence-based treatment protocols. Supervision requires

a deep, critical understanding of the theoretical, research and practice dimensions

of these treatment approaches, as well as an ability to deconstruct these approaches

into concrete, practical applications. As an analogy, not all outstanding athletes are

successful coaches: applying skills is different from teaching and supporting skill

development in others. There is a large literature related to adult education and

training that is beyond the scope of this handbook. However, Renner (1999) provides

a summary of adult learning theory and practice that is concise yet comprehensive.

Opportunities for observation and practice

Clinical supervisors need to resist the temptation to use clinical supervision time

primarily for discussing cases and dispensing advice. Learning by doing, or active

learning (based on the learning theory known as constructivism), has become the

hallmark of current approaches to teaching and learning (Tight, 1996). Examples

of incorporating active learning into supervision might include:

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Clinical Supervision Handbook

• role-playing a challenging case example with the clinician

• live observation and feedback of a clinical consultation

• practising a discrete skill (such as complex reflections in motivational interventions)

with clinicians

• playing a video recording of a session with frequent pauses for critical, reflective

commentary by the clinician and/or clinical supervisor/group.

• In all of the above examples, clinical skills are examined in the context of the

evidence-based treatment application being applied or demonstrated.

Psychological safety and constructive feedback

Demonstrating skills in front of clinical supervisors and peers is often experienced

as “high-risk” by clinicians, and demands that clinical supervisors convey collegial

respect, positive regard and non-judgmental acceptance. Fostering a positive learning

climate can be better accomplished when clinical supervisors model their willingness

to take risks and are transparent about the areas they need to further develop. For

example, the clinical supervisor could first demonstrate practice activities before

asking clinicians to do so. In addition, feedback is generally experienced as more

constructive and salient when it is neutral, concrete and references the skills or

philosophy underlying the clinical approach.

In summary, advancing skills development in evidence-based practice approaches

means that clinical supervisors must:

• facilitate a shared understanding and appreciation of the meaning of evidencebased

practice

• be proficient in supporting clinicians to learn evidence-based approaches and

apply these approaches to practice

• apply and critique concrete strategies and tools in a safe and supportive learning

context.

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Cultural Competence and Clinical Supervision

Cultural Competence and

Clinical Supervision

The diverse, multicultural makeup of our society means we must carefully consider

issues of race, culture and other dimensions of diversity. Developing cultural competence

is now “a recognized requirement for achieving professional standards in therapy

and supervision training” (Divac & Heaphy, 2005, p. 282). The need for cultural

competence in mental health practice has been described as a professional as well as

a moral and ethical imperative. As noted by Sue and colleagues:

White culture is such a dominant norm that it acts as an invisible veil

that prevents people from seeing counseling as a potentially biased

system.…What is needed is for counselors to become culturally aware,

to act on the basis of a critical analysis and understanding of their

own conditioning, the conditioning of their clients, and the sociopolitical

system of which they are both a part. Without such awareness,

the counselor who works with a culturally different [sic] client may

be engaging in cultural oppression using unethical and harmful

practices. (Sue et al., 1992, p.72-73)

CULTURAL COMPETENCE

The term cultural competence was first defined by mental health researchers over a

decade ago as “a set of congruent behaviors, attitudes, and policies that come together in

a system, agency, or amongst professionals and enables that system, agency or those

professionals to work effectively in cross cultural situations”(Cross et al., 1989 p. iv).

In this definition “culture” refers to integrated patterns of human behaviour that

include the language, thoughts, communications, actions, customs, beliefs and values

of racial, ethnic, religious or social groups. Culture should not be conceptualized

narrowly in terms of only race, ethnicity, and country of origin; instead, culture must

be defined broadly as inclusive of various diversity dimensions including, but not

limited to, age, gender, gender identity, sexual orientation and socio-economic status.

“Competence” implies having the capacity to function effectively as an individual

and an organization within the context of the cultural beliefs, behaviours and needs

17


presented by the clients, consumers and their communities (Cross et al., 1989). Thus

cultural competence is differentiated from cultural sensitivity and awareness by a

need for action and altering practices to effectively interact with different cultural

groups. (cdc National Prevention Information Network, n.d). Cultural competence

in clinical care encompasses an understanding of the other’s worldview, a critical

understanding of the dynamics of power and social location in our society, and the

ability to adapt one’s practice accordingly (camh Diversity Programs Office, 2003).

There are many frameworks and models of cultural competence across the various

disciplines. A critical examination of the literature, however, reveals remarkable similarity

in the requisite competencies. The differences are more in the area of emphasis

(Haarmans, 2004). There is general agreement that clinical cultural competence

comprises three domains as described by Sue and colleagues:

• awareness of attitudes, values and biases (affective domain)

• knowledge (cognitive domain)

Clinical Supervision Handbook

• skills required to be effective in cross-cultural encounters (behavioural domain).

In addition, a fourth dimension of power/relationships has also emerged as an

important domain for consideration (cno, 2003; Sandowsky et al., 1994). This

domain refers to the dynamics inherent in a clinician-client relationship with similar

and different cultural values, racial identity attitudes and issues of power, control,

and oppression (Haarmans, 2004). For a more comprehensive discussion of clinical

cultural competence, see Haarmans.

Development of cultural competence is generally recognized as a process that evolves

with time, experience and deliberate attention. As such, cultural competence is often

described on a continuum, with one end reflecting little recognition of the need for

incorporating culture into care, and the other end where cultural knowledge and

insight lead to innovative practices and positive outcomes for the client, the clinician

and the health care organization (Cross et al., 1989; Tripp-Reimer et al., 2001).

Although much has been written on the need to develop cultural awareness, skills

and knowledge to provide clinical supervision (D’Andrea & Daniels, 1997; Sue, 1991),

little information is available on how to imbed and develop cultural competence

within clinical supervision (Leong & Wagner, 1994; Johnson, 1987). The lack of an

operationalized definition for clinical cultural competence (ccc) and a corresponding

lack of validated, comprehensive measures needed for training and research are

major impediments to the development of cultural competence (Lo & Fung, 2003).

18


INCORPORATING CULTURAL COMPETENCE INTO

CLINICAL SUPERVISION PRACTICES

Within the supervision process, the need for cultural competence is evident at two

distinct, but inter-related levels. These are:

• developing a clinician’s capacity in cultural competence

• addressing the dynamics of culture and difference within the superviseesupervisor

relationship.

The supervision process is an effective vehicle for assessing a clinician’s multicultural

competence and further developing cultural awareness, knowledge and skills. It has been

described as an effective process for examining the conscious and the unconscious

pathologizing of clients and therapists (Tummala-Narra, 2004). Raising cultural

issues encourages self-exploration and can be “eye opening,” leading to development

of new perspectives and practices (Cashwell et. al., 1997). Supervisors need to develop

strategies that move supervisees from knowing that cultural differences exist

(cultural sensitivity) to knowing how to work with individuals from diverse groups

(cultural competence) (Cashwell et al., 1997). To support this journey, intellectual

understanding needs to be augmented by actual examples from practice. An understanding

of how our own gender, race, ethnicity, religion, socioeconomic class,

generation and geographical region shape our sense of self can result in increased

appreciation of how others are shaped by the same variables (Okun et al., 1999).

Power dynamics

Cultural Competence and Clinical Supervision

The challenges of cultural dynamics are not limited to work with clients; they apply

equally to the process of supervision itself and the supervisor-supervisee relationship.

Research examining the experiences of supervisees of colour highlights the

perception that the supervisors’ clinical approaches are often “rooted in a limited,

dominant culture perspective, despite their good intentions to attend to issues of

difference” (Tumala-Narra, 2004, p. 304). In some instances, supervisors may minimize

racially or culturally relevant material, either because of a lack of knowledge, or due

to fear of being perceived as a racist. Supervisors who expect themselves to be “all

knowing” can feel threatened by the client’s or the supervisee’s cultural knowledge.

However, such supervisory encounters perpetuate racial enactments and can be

silencing for the therapist and the client (Tummala-Narra, 2004).

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Clinical Supervision Handbook

Another emotion that can impede the supervision encounter is shame. Lybarger

(2001) describes three progressively deeper levels of shame: embarrassment, humiliation

and mortification. Embarrassment is associated with feeling self-conscious, ill

at ease, disconcerted or flustered; humiliation occurs when there is a perceived loss

of pride or dignity and mortification occurs when humiliation is deep and is associated

with feelings of helplessness, hopelessness and despair. Tummala-Nala suggests

that the lack of supervisor initiative to explore issues of diversity can contribute to

lowered self-esteem and the experience of shame, which in turn may trigger defensive

reactions such as avoidance and withdrawal on the part of the supervisee. Although

it is important to explore diversity issues in the supervisory encounter, it needs to be

done with an awareness that racial discourses continue to be highly emotional and

can lead to feelings of vulnerability. For these reasons it is critical to determine the

extent to which the supervisory relationship is a safe space for exploration of such

issues (Tummala-Nala, 2004).

Supervisory competencies and

strategies for addressing diversity

While there is no one approach to developing cultural competence for clinical supervision,

there are a variety of methods that can assist supervisors. It is critical that

supervisors “walk the talk.” The walk is a journey that enhances personal growth and

identity development. “Culturally skilled counselors are constantly seeking to understand

themselves as racial and cultural beings and are actively seeking a nonracist identity”

(Pedersen, 2000, p. 20). The cultural awareness and skill development of clinical staff

is often dependent upon clinical supervisors who consistently model behaviour that

is reflective and acknowledges the power held in a supervisory relationship.

Clinical supervisors are in the unique position to be mentors, teachers, supporters

and evaluators. This unique relationship of supervisor-supervisee is markedly different

than the relationship staff members form with a client (Baird, 1999). Culturally

competent supervisors are able to understand and put into perspective the worldviews

of their diverse supervisees and clients and reflect the experience to the staff.

During supervision they are able to create a positive environment where there is

an opportunity for staff members to address and discuss issues that may be related

to culture in an open and explicit manner (D’Andrea & Daniels, 1997). Culturally

competent supervisors have the ability to work across cultures and work with clinical

staff to do the same.

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Supervisors can influence clinicians by helping them investigate ways to maintain

language competency while communicating or when trying to understand the

diverse communication styles of their clients. In supervision, they can share valid

and reliable assessment tools and techniques (Gopaul-McNicol, 2001; Paniagua, 1998).

Supervisors can also use a variety of strategies to address issues of diversity, race and

culture. However, a willingness to engage in ongoing self-examination and an openness

to new and unknown information are foundational requisites for these strategies

(Tummala-Narra, 2004). Some approaches to develop cultural competence include

role play, interpersonal process recall, first person feedback and metaphor (for a

detailed discussion see Cashwell et al., 1997; Divac & Heaphy, 2005; Hernandez, 2003).

Tummala–Narra (2004) describes four strategies that can be utilized by supervisors:

• increasing cultural knowledge

Cultural Competence and Clinical Supervision

• initiating the discussion of race and culture

• attending to transferential responses

• engaging in multicultural education.

Although no individual is expected to have detailed knowledge about every cultural

group, it is important for supervisors to attain a “reasonable” level of cultural awareness,

knowledge and range of communication skills in order to model these to their supervisees

(Garret et al., 2001). This generic cultural knowledge includes knowledge of:

• institutional barriers that prevent some clients from using mental health services

• history, experience and consequences of oppression, prejudice, discrimination,

racism and structural inequalities

• the heterogeneity that exists within and across cultural groups and the need to

avoid overgeneralization and negative stereotyping (Haarmans, 2004).

While it may be important at times for the supervisor to ask the supervisee about

issues pertinent to a particular cultural group (or for the therapist to ask a client),

such inquiries should not be considered sufficient to serve as a knowledge base that

guides supervision or psychotherapeutic interventions (Tummala-Narra, 2004).

Supervisors and clinicians need to make a commitment to acquire such knowledge

as part of their ongoing learning, and use the supervisee or client to validate the

issues pertinent to them as members of particular groups.

Initiating discussion of cultural and diversity issues is another recommended strategy.

Such initiation by the supervisor recognizes the power dynamics of the relationship

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Clinical Supervision Handbook

and challenges the traditional notion of neutrality and normalizing the complexity

associated with diversity (Tummala-Narra, 2004). It is important for supervisors to

create a safe environment where such discussions can occur openly and without the

experience of shame. Such discussions can also highlight communication barriers that

may be rooted in cultural differences that need to be addressed (Garrett et al., 2001).

Encounters between clients, supervisees and supervisors from different cultures

involve a set of interconnected transference reactions (Tummala-Narra, 2004, p. 309).

These reactions may be based on individual characteristics as well as characteristics

associated with particular racial or cultural groups. In reflecting on transferential

responses it is important to critically reflect on one’s own assumptions and traditional

views. It is also important to consider the ways in which racial and cultural

identity shapes social and psychic realities and interpretations. Such a stance will

minimize avoidance and treatment of cultural issues as “extraneous” or “exotic”

(Tummala-Narra, 2004).

Lastly, it is important for supervisors to engage in ongoing education on multicultural

perspectives as they relate to psychopathology and therapy. Research indicates a

strong link between self-rated competence and the number of diverse clients seen by

the therapist, suggesting that treating diverse client groups is an important training

experience (Allison et al., 1996). It is also important for supervisors to seek out literature

and engage in discussions on race, culture and mental health. Such exploration

and reflection will assist the supervisor and the supervisee in understanding the

complexities of culture and its relationship to mental health and mental illness.

In summary, the rapidly changing demographics of clients require increased attention

to culture and the supervisory relationship. The tools for ensuring supervisees’ cultural

competence are within reach and require a commitment from each one of us as

clinicians and as supervisors. Cultural competence is a critical skill for both individual

and group supervision and can be developed through a variety of experiential

learning approaches. Integral to this process is reflection on such issues as power

dynamics, divergence of world views and stereotyping.

22


IMPLEMENTING

CLINICAL SUPERVISION

Beginning Clinical Supervision

THE CLINICAL SUPERVISION RELATIONSHIP

AND CONTRACTING

As you begins to meet with clinicians, it is useful to identify what one already knows

about clinical supervision, what the program leadership hopes to obtain from clinical

supervision and what the clinician knows about and expects from the clinical supervision

process. This is an opportunity to develop relationships and clarify expectations.

In the process of contracting, you can begin to provide a foundation for the clinical

supervisory relationship. Although this is useful to do at the beginning, it is important

to remember that relationship clarification and contracting will likely occur throughout

the clinical supervisory process.

Shulman (1993) identifies four main areas of contracting as you develop relationships

in the beginning phase of a clinical supervisory situation:

• share the sense of purpose

• describe the clinical supervisor’s role

• elicit feedback from the clinician on his or her perceptions of clinical supervision

• discuss mutual obligations and expectations related to the clinical supervisor’s

authority.

Sense of purpose

The clinical supervisor should discuss the purpose and expectations of clinical

supervision with the clinician. A shared purpose offers clarity about the clinical

supervisory process for the program staff, the clinical supervisor and clinician. You

should discuss several definitions of clinical supervision with the program and

23


clinician to learn how the program staff will use the clinical supervision process in

day-to-day work.

Clinical supervisor’s role

Clinical Supervision Handbook

As programs and services in health care evolve, new leadership roles (e.g., discipline

chiefs and advanced practice clinicians / nurses) have been created to carry out the

functions of clinical supervision and support of staff. There is a growing recognition

that these roles are distinct from that of the manager in that the manager is the individual

responsible for the administrative functions of the program. These leadership

roles of clinical supervisor and manager have many areas of shared responsibility

such as program development and the facilitation of team processes. The challenge

for people in these roles is to navigate the boundary between performance management

and clinical supervision. The challenge is to deliver supervision that provides

enough of a safe space for front-line staff to explore practice issues, while at the same

time making sure that administrative managers feel adequately informed about matters

under their purview.

Elicit feedback from the clinician

A discussion about perceptions, beliefs and attitudes about clinical supervision can

help to demystify the process. A discussion of how the clinician felt about her or his

last clinical supervisor or the clinical supervision model can help to clarify present

expectations and allow constructive feedback. This is an opportunity to begin to

develop trust and understanding with the clinician.

Discuss mutual obligations and expectations related to

authority

Although clinical supervisors may be uncomfortable with discussing authority, they

should discuss the balance between their supervisory and managerial roles with

every one they supervise as soon as possible in the supervision relationship. Many

clinicians are concerned about when information will be shared with management

and if the information will be included in a performance review. For example: Will

the manager attend some of the sessions? Will management receive reports about

the clinical supervision sessions? It is important to be clear about expectations,

24


Beginning Clinical Supervision

procedures and roles so that clinicians can develop a clear understanding of the

parameters of the clinical supervision process.

Dealing with suboptimal standards of practice

What are the clinical supervisors’ obligations once they have become aware of

suboptimal standards of practice?

To answer this question, we need to consider at least two scenarios:

• when issues arise spontaneously in supervision

• when issues are generated from performance management and supervision.

When issues arise spontaneously in supervision

A well-functioning supervision relationship can resolve many challenges. A good

general rule is that a practice issue identified in supervision sessions can remain

within the confines of supervision as long as the client’s care has not been seriously

compromised and the supervision process is yielding results. If either of these

conditions were not met, the clinical supervisor would need to consult with the

manager. For example:

• When clients complain about inappropriate staff behaviour, the manager should

be informed and directly involved in the plan to follow up on the complaint,

since the event could lead to disciplinary action. The clinical supervisor’s role

can be to follow up with the areas of concern highlighted by the complaint and

to monitor the staff member’s progress in the hope that he or she does not repeat

the inappropriate behaviour.

• If the clinician and the clinical supervisor don’t agree that the clinician’s behaviour

is a concern, then the clinical supervisor should inform the manager and all could

decide together how to proceed.

• If the clinical supervisor learns at any time that a clinician has broken the code

of conduct of the organization or has violated the code of ethics as established by

the clinician’s regulatory body, then the manager must be informed.

Even when the clinical supervisor takes an issue outside the confines of clinical

supervision, the consultation with the manager can be considered a resource to help

to resolve a problem that may not require performance management and discipline.

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Clinical Supervision Handbook

When issues are generated from performance management processes

Any clinical supervision task generated by the performance management system

should include the following:

• a precise description of what aspect of the staff member’s practice is below standard

• a precise description of how a staff member’s practice has to change in order to

meet expectations

• a precise plan outlining what kind of documentation will be required from the

clinician to monitor performance

• the maximum length of time available for achieving the task at hand

• details on how the clinical supervisor will report progress and to whom these

reports will be given

• an understanding of the consequences if there is a recurrence of the suboptimal

practice.

Attending to the above details will assist clinical supervisors and staff in marking the

end of a specific, performance-management supervision task, and the restoration of

a “business as usual” clinical supervision relationship.

Discuss the goals of clinical supervision

It is helpful to talk about the atmosphere clinicians believe they need to develop

their clinical skills. This is likely to entail discussions about the importance of creating

a safe place for clinicians to share information, thoughts and feelings related to

their work. Clinical supervision is different from therapy in that clinical supervision

focuses on the clinicians’ struggles and challenges as they relate to client care. The

process of developing trust and safety in the relationship is introduced in the initial

meeting and is reinforced through the experiences of interacting with the clinical

supervisor in the day-to-day work.

It is also useful to discuss with the clinician the types of approaches available in the

program for professional development and growth. For example, in some programs

two-way mirrors can be used for direct supervision, coaching and feedback. In

others, audio- or videotapes are available. Some programs present opportunities

for learning through co-therapy and review, while others will rely primarily on

case presentation and consultation. This is further discussed in the next section.

Contracts can be general or specific with regards to learning goals, activities and

26


Beginning Clinical Supervision

time frames. Contracts can be verbal or written. The following case example

illustrates the process of establishing a verbal contract.

CASE EXAMPLE: DISCUSSING THE GOALS

OF CLINICAL SUPERVISION

Regina, a new clinician who recently graduated from school,

starts a permanent position as an addiction therapist in the residential

program. As part of her orientation, Regina is asked to

meet with the clinical supervisor (an advanced practice clinician)

and manager to discuss roles and expectations, the role of clinical

supervision in this setting, the process of group clinical supervision

and the scheduling of individual clinical supervision. The

clinician is also offered a few definitions of clinical supervision

that are used in this setting.

Because she will report to both the clinical supervisor and manager,

Regina is given some guidelines about areas appropriate for

discussion with the clinical supervisor and other areas to be

discussed with the manager. The APC role focuses on practicerelated

issues through education and support while the manager’s

role is more administrative, as well as being supportive.

In building the relationship with the clinical supervisor, Regina is

asked questions about past clinical supervision as a student as

well as any questions or concerns she has about working with the

clinical supervisor in this setting. From this discussion, the clinical

supervisor learns that Regina experienced her student supervisor

as holding grudges and often felt punished for earlier mistakes in

her placement. This information leads the clinical supervisor

to be sensitive when giving feedback, to acknowledge that the

clinician cannot always make perfect choices and to articulate her

hope that the clinician approach her if she were unsure of her

work in the early days, as a way to obtain help and support.

The clinical supervisor also discusses circumstances that are

somewhat unique to the program. Unlike other settings, there is

opportunity for the clinician to connect with the clinical supervisor

around daily clinical issues. Also, there are some situations such

27


as discharging a client, where a consultation from a representative

from management is required. The clinical supervisor would

share, upon request from the manager, the level of participation

negotiated for clinical supervision, consistent with the initial

discussion of roles and responsibilities.

Finally, the clinician is asked to reflect on her work as a student

and identify some goals she has for this staff position. Regina is

also asked if there are any resources or courses that might

enhance her clinical practice.

WHEN CLINICAL SUPERVISION IS

AT THE REQUEST OF THE MANAGER

When clinicians are told that they are required to attend clinical supervision, a variety

of feelings may arise for both clinician and clinical supervisor. The clinical supervisor

may believe that he or she should have offered supervision earlier or may wonder if

he or she could have provided a more supportive environment so the clinician could

have come to supervision sooner. From the perspective of the clinician, there may be

positive feelings because the clinician has struggled with a clinical situation and now

feels supported by the added attention or help. Alternatively, clinicians can feel very

stressed as they may feel targeted as having done something wrong. Clinicians may

feel that they have been betrayed by sharing their struggle with another member of

the team, and telling the truth about a difficult situation or be embarrassed because

other clinicians told management about unsafe clinical practices. In circumstances

when a clinician is returning to the workplace after disciplinary action, there can be

feelings of anger and embarrassment.

Clinicians may be told to attend clinical supervision because they need to:

• comply with the mandatory regulating body

• acquire skills (required by the program) that can be learned in clinical supervision

• attend clinical supervision as part of a disciplinary action or as part of a return

to work procedure

• integrate evidence-based practice into their work

• focus on client-centred care

Clinical Supervision Handbook

28


• manage burnout and workload

• concentrate on a specific deficiency in clinical competency that

has been identified.

Clear contracting is crucial under these circumstances as often the perception of trust,

between team members and management, has weakened and some type of a report is

expected. Some examples of questions to consider for the purpose of clarity are:

• Will the requested need for clinical supervision address the concern entirely or

are there other important components (i.e., training that may or may not be part

of the role of the supervisor)?

• What is the time frame expected for the clinician to accomplish the goal of

clinical supervision?

• What details in the report does the manager expect?

• What will happen if the clinician does not attend or comply?

• What are indicators of compliance?

Beginning Clinical Supervision

• What will happen if the clinical supervisor does not write a positive report?

It is helpful to clarify the clinical supervisor’s role to ensure the best outcome of

clinical supervision. Once the role has been determined, the manager, clinician and

clinical supervisor should meet to review the expectations and document what is

being requested.

Similar to the processes described earlier regarding contracting in general and establishing

the working relationship with the clinician, it can be helpful to obtain feedback

about how the clinician feels about the structure of the supervision process.

Additionally, the supervisor can ask the clinician for his or her input, such as: “Since

we are meeting, what would you like to get out of this scheduled time?” Connecting

with the clinician about his or her clinical goals can help the clinician see the value

of clinical supervision, improve his or her professional skills and fulfil the needs of

the program.

CASE EXAMPLE: MANAGER-REQUESTED

CLINICAL SUPERVISION

Jacob, a social worker on a psychiatric inpatient unit, continued

to see the parents of a client after the client was transferred to

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Clinical Supervision Handbook

another clinical team. Jacob did not believe the new social worker

understood the family’s distress or perspective because he

thought he could better identify with their Eastern European background.

When management learned that Jacob was seeing this

family, it was decided that he had overstepped his boundaries

and should have referred the family to the new clinical team. He

was disciplined and asked by his manager to attend clinical

supervision.

Jacob came to clinical supervision not really knowing what to

expect. He recognized that he had overstepped a boundary; however,

he was upset with being disciplined and thought his manager

had treated him unfairly. He also did not want talk to anyone

about the situation because he did not believe that he would be

supported if he sought out clinical supervision. A contract was

developed to reflect the expectation to discuss boundary crossing

and ways that Jacob could approach management for more support

if needed. Also, Jacob was asked if there were any other areas

of skill that he would like to develop in clinical supervision. He

mentioned that given the increased workload in documentation,

he would like some guidance around documentation.

A meeting was set with Jacob, the clinical supervisor and the

manager to discuss the goals of clinical supervision (boundaries,

asking for more support and documentation). It was negotiated

that the individual sessions occur once a week for one month as

this appeared to be adequate time to discuss these topics. After

one month, the clinical supervisor—with Jacob’s input—would

complete a report of Jacob’s progress. If more time were

required, this would need to be renegotiated.

In clinical supervision, Jacob discussed his current clinical cases,

the clinical supervisor brought thoughtful articles and information

for Jacob to consider and documentation was reviewed. After

one month, Jacob felt more confident in his work and better able

to ask for assistance in the future.

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Beginning Clinical Supervision

GIVING FEEDBACK ON PERFORMANCE

The clinical supervisor and clinician should regularly review the clinical supervision

process and recontract when necessary. Later in the handbook, we will discuss ways

the clinical supervisor can request and receive feedback (see p. 92); this section is

meant to provide some ideas about offering feedback to clinicians.

Clinicians will usually have many opportunities to receive feedback. Although

clinicians will learn from a variety of sources, the clinical supervisor has an explicit

responsibility to assist in the clinicians’ development and growth.

The task of providing feedback may feel quite strange especially if the clinical supervisor

has recently been promoted from the role of clinician. A discussion with peer

supervisors about the change of roles at this time can be invaluable. There are many

reasons why a clinical supervisor will have the capacity to provide unique and valuable

feedback. The clinical supervisor:

• can often compare strategies used by a variety of supervisees and offer

opportunities to develop consistency among clinicians

• has more time to look at the bigger picture of the organization’s values and

goals and help to match practice to the organizational context

• is not working directly with the client and therefore has the opportunity to

review issues with more distance and perhaps clarity

• is simply able to provide alternate perspectives that have not been considered.

Feedback should highlight strengths as well as identify opportunities for learning. It

is important to take any opportunity to offer positive feedback. If a clinician shows

strength in some aspect of the work, the clinical supervisor can use this as an opportunity

to highlight the work. By offering this strength-based approach to feedback

early and often, the clinician can place any difficult or change-oriented feedback in

the overall context of a positive work environment that values the clinician’s strengths

and need for continuous learning.

When offering feedback that may be difficult for the clinician to hear, the clinical

supervisor will want to provide an optimal learning environment. The best option is

to offer the feedback in regular individual sessions. If this is not possible, it is wise to

find a time that the clinician can meet without interruption in a confidential space.

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Clinical Supervision Handbook

It is helpful to offer the feedback in a way that is specific and concrete. Sometimes

the feedback is about a particular situation and will allow an opportunity for the

clinician to respond and perhaps offer more information. If the issue is not linked

to a specific incident or situation, the clinical supervisor might need to provide

concrete examples to support the feedback. Providing the clinician with an example

illustrates the precise nature of the concern and also gives the clinician a chance

to clarify any misunderstandings. The clinical supervisor may also wish to provide

this feedback in writing.

It is important to offer the feedback in a timely fashion. Although it can seem timeconsuming

to give clinicians feedback that may seem minor, early feedback can

give clinicians the opportunity to absorb the information, respond faster and use

other resources in addition to clinical supervision to assist with making changes

to their practice.

CASE EXAMPLE: FEEDBACK ON PERFORMANCE

Janet is a clinical nurse in an outpatient addiction treatment service.

At her bi-weekly clinical supervision, Janet described working with

a client who was “mandated” by the child protection authority

Children’s Aid Society (cas) and who she felt was “just going

through the motions” to get her child back. The client had stopped

using crack cocaine; however, she reportedly used marijuana

occasionally.

The marijuana use and the fact that the client was not interested

in making any psychological changes concerned Janet and were

the reasons she was asking for clinical supervision. The fact that

the client was intending to end treatment in two more sessions

also caused Janet to worry that she had not done all that she

should to help effect change.

The clinical supervisor first wanted to point out how the sessions

with the client appeared successful in relation to her goals

of treatment, part of which was to see the client stop using

crack. Janet could agree that the previous sessions may have

been helpful but was unsure about whether she had sufficiently

addressed her client’s cannabis use. They discussed the importance

of the therapeutic relationship apart from the client’s

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cannabis use—which Janet felt was quite positive—as well as the

importance of the client’s efforts and strengths outside of the

therapeutic relationship.

The clinical supervisor then explored feelings around the client

“going through the motions” and discussed if this interfered with

Janet’s lack of feelings of success about this client. The clinical

supervisor then asked about whether cas would object to

occasional marijuana use, given that her doctor had prescribed

her marijuana, and concluded this would likely not be a great

concern to cas.

Finally the clinical supervisor gave her some feedback about her

approach with the client. She told Janet that she could use the last

two sessions to tell the client what she really thought about the

marijuana use, or she could work toward cultivating a

relationship with the client so if she ever wanted to address the

marijuana use or her feelings around using crack cocaine, this

would be a safe place for the client to return regardless of whether

she was still involved with cas.

Janet was able to see that her approach to the client had been

focused more on substance use (very common in a substance

use service) and less on maintaining a relationship with the client

to foster further growth and development if the client wished to

seek out further treatment.

LEARNING STYLES

Beginning Clinical Supervision

A learning style is “a predominant and preferred approach which characterizes an

individual’s attitude and behaviour in a learning context” (Bogo & Vayda, 1998,

p. 100). Clinicians may not have considered how their learning styles or needs might

differ from those of their colleagues or the clinical supervisor. Learning styles can

vary on a variety of dimensions.

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TYPES OF LEARNING SKILLS

structured unstructured

method description intuition

concrete abstract

active reflective

individual group learning

visual auditory

self-directed clinical supervisor-directed

There are a variety of models of learning styles available for learners to consider.

Kolb (1984) has developed a highly regarded and utilized model. He presents how

people can learn on two axes: a perceptual continuum from concrete to abstract

and a processing continuum from active to passive. From this work, he presents

four distinct learning styles:

• accommodator

• diverger

• converger

• assimilator.

Clinical Supervision Handbook

Accommodator style (feel and do): preference for concrete

experience and active experimentation

Accommodators are “hands on” and rely on intuition rather than logic. They prefer

a practical and experiential approach. Accommodators may prefer to rely on instinct

instead of providing a logical response. This is a useful approach when the situation

requires action and initiative. Accommodators work well on teams to complete tasks.

They set targets and work in the field trying different ways to achieve their objectives.

Learning activities include shadowing, doing the clinical work and talking about it in

clinical supervision or having the clinical supervisor observe the work.

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Beginning Clinical Supervision

Diverger style (feel and watch): combination of concrete

experience and reflective observation

Divergers are often able to look at a situation from different perspectives. Such

learners are sensitive, and prefer to watch rather than do, tending to gather information

and use imagination to solve problems. They prefer to work with groups, to

listen with an open mind and to receive personal feedback.

Learning activities include shadowing, role modelling and reviewing teaching tapes.

Converger style (think and do): abstract conceptualization

and active experimentation

Convergers are problem solvers. They prefer to focus on technical tasks, and are less

concerned with relying on others to learn. They are best at finding practical uses for

ideas and theories. They are good researchers and often have technological abilities.

They like to experiment with new ideas, to simulate and to work with practical

applications.

Learning activities include reading various theoretical perspectives, getting feedback

from clinical supervisor reviewing their clinical work, developing treatment plans

and role plays.

Assimilator style (think and watch): combination of abstract

conceptualization and active experimentation

Assimilators are logical and concise. They tend to focus on ideas and concepts. They

look for a clear explanation rather than a practical response. They excel at understanding

wide-ranging, often theoretical information and organizing it in a clear and

logical format. They are less focused on people and more interested in ideas and

abstract concepts. Like the converger, the assimilator likes a scientific approach.

They prefer to read, attend lectures, explore analytical models and have time to think

things through.

Learning activities include reading various theoretical perspectives, viewing learning

tapes, developing treatment plans and watching other clinicians.

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Clinical Supervision Handbook

LEARNING STYLES AND CLINICAL SUPERVISION

While most people may see aspects of themselves reflected in each style, each discrete

style can be regarded as a particular type. These types provide ways to help

both clinician and clinical supervisor identify their own preferred learning styles.

Most people will have a mix of styles, but one usually predominates. When clinician

and supervisor have different learning styles, each can expand their repertoire and

adapt to how information is presented and absorbed by the other, producing rich,

new ways of extracting optimal learning from various situations. Supervisors can

assist clinicians to use familiar and new learning styles to try new and challenging

practices, acknowledge discomfort and set goals that overcome barriers.

The supervisor can also share his or her own preferred learning style and then discuss

learning options outside of the clinical supervisor’s preferred learning style. This helps

to stimulate discussions about how the clinician can further enhance his or her clinical

practice and allow for a variety of approaches to be used depending on the clinical

situation. In this way, the clinical supervisor works with the clinician to construct

the best learning environment.

CASE EXAMPLE: LEARNING STYLES

In developing a new psychotherapy group, a clinician had done a

great deal of preparation by reading books on the topic, speaking

to another therapist who leads this type of group and observing a

few sessions of this type of group. However, the clinician still felt

there was more to learn. The clinical supervisor thought there

was little more to offer the clinician to assist in preparation, and

therefore decided to talk about learning styles. The clinician

acknowledged that he was more reflective and enjoyed conceptualizing

the group from descriptions that emerged from the literature.

The clinical supervisor acknowledged that he learned best

with active participation and would be the type of learner who

would start the group and intuitively learn more as he went along.

This allowed both to pause and reflect on what else was needed

for the clinician to feel able to start the group. It was decided that

the clinician was likely ready to start the group in two weeks and

both would assess progress as the group went forward.

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As this example illustrates, the clinician and clinical supervisor

were able to address the learning needs of the clinician by first

discussing their own unique learning styles. These discussions

can further assist in developing new ways to plan, conduct and

evaluate the learning. Often this will come about as part of a discussion

when some type of mismatch is occurring. This discussion

can lead to a positive and productive discussion of clinical

practice.

Ongoing Clinical Supervision

METHODS OF CLINICAL SUPERVISION

There are a variety of methods used to provide clinical supervision. Some include

direct observation of the clinician and/or supervisor at work with clients and others

rely on review of clinicians’ work by examining audio, video or written records or by

verbal case presentations. This section discusses four of these methods:

• demonstration / reflecting mirrors

• co-therapy

• role-playing

• reviewing audio and / or videotapes.

Ongoing Clinical Supervision

These methods address the various learning styles described by Kolb: accommodator,

diverger, converger and assimilator.

Demonstration / reflecting mirrors

Demonstration

Typically, the clinical supervisor and clinician meet in advance and discuss a particular

struggle that the clinician is having or identify a particular set of skills that the

clinician needs to learn. Then the clinical supervisor meets with the clinician and his

or her client and takes the lead in the interview with the client. The clinical supervisor

debriefs with the clinician afterward, asking the clinician what he or she noticed and

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Clinical Supervision Handbook

how the clinical supervisor’s responses were similar and different to those of the

clinician. The clinician is present during the interview between the client and the

clinical supervisor and the debriefing is an opportunity for the clinician to compare

what the clinical supervisor did with what the clinician would have done if he or

she were conducting the interview.

Reflecting Mirrors

In the reflecting mirrors technique, the clinical supervisor is in a room with the

client. The clinician sits outside of the room, looking through a reflecting mirror.

The process is the same in terms of how the interview is set up—purpose, goals,

process, debriefing. The supervisor and clinician roles can be reversed, with the

clinical supervisor observing the clinician interview the client.

CASE EXAMPLE: DEMONSTRATION

Both the Keeping Safe and Enhancing Women’s Well Being

groups are co-facilitated with a member of staff or a student as a

way of modelling how to run the group. The clinical supervisor

shows them how to:

• help the group establish norms

• review the content of the handouts in a way that respects the

needs that the clients bring forward in the sessions

• manage conflict within the sessions

• ensure there is a balanced opportunity for clients who tend to be

silent and for those who are more outspoken to share the floor

• elicit opportunities for clients to hear the commonality of experience

and learn that they have something to offer one another

• demonstrate respect for the clinician/student co-facilitator by

verbally underlining meaningful interventions that she or he

makes and returning to them if they get lost in the session.

CASE EXAMPLE: ONE-WAY MIRRORS

For the Enhancing Women’s Well Being Group, the clinical supervisor

facilitates the sessions with a graduate student in a room

that has a one-way mirror. While this method is used for student

learning, it can also be used for staff development. Other students

and staff are invited to observe. They are given a sheet of

paper with specific questions to reflect on as they watch the

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group. The clinical supervisor uses these questions to shape the

learning experience for all supervisees. The questions are:

1. What is different and similar about this group and other groups

you have observed or participated in?

2. How is gender playing itself out in this group? What themes do

you notice?

3. How are diversity issues experienced in this group (i.e., class,

culture, sexuality)?

4. What questions do you have about the choices that the co-facilitators

made in terms of facilitation during this session?

General comments and debriefing

A range of questions can be used depending on what the supervisor intends observers

to learn from the observation experience. For example, MacKenzie (1990) developed

a Group Climate Questionnaire that asks observers (and group members and facilitators)

to rate the group as a whole along various dimensions that break into three

subscales: engaged (a positive working environment), conflict (a negative atmosphere

with anger and distrust) and avoiding (of personal responsibility for group work).

Using a tool like this increases observers’ awareness of the interaction between members

and between members and facilitators. The tool reinforces the differences between

working with clients individually and within a group, highlighting areas to explore

further in future sessions when gaps are noticed.

After the group, the co-facilitators debrief with the observers, discussing their responses

to the questions as well as processing their observations of group member interactions

and what they observed the co-facilitators do. This provides an excellent learning

opportunity for all involved since there are often a variety of strategies that can be

used at any given time.

Co-therapy

Ongoing Clinical Supervision

Co-therapy is the joint facilitation of a client group by two clinicians—in this case,

the clinician and the clinical supervisor. This allows the clinician to observe the

strategies used by his or her clinical supervisor, and it enables the clinical supervisor

to observe the clinician’s interventions and to provide immediate feedback.

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Clinical Supervision Handbook

CASE EXAMPLE: CO-THERAPY

The clinical supervisor meets with the staff member before he or

she begins co-facilitating in order to provide some background /

history of the group, its goals, co-facilitators’ roles, what the clinician

can expect to occur, and to explore what the clinician feels comfortable

doing. The clinical supervisor continually evaluates the

clinician’s involvement and interventions over time and monitors

the clinician’s desire to take more risks within the group.

Prior to each session, the clinical supervisor and staff member

(co-facilitators) meet briefly to discuss the plan for that day. For

the Enhancing Women’s Well Being Group, which is a 14-session,

closed outpatient group, there is greater opportunity for continuity

since the same people facilitate for the whole cycle. The cofacilitators

can review previous sessions and decide what needs

to be followed up on and what roles they might each take for the

particular meeting.

After the session, the clinical supervisor takes some time to

debrief. During this time, the co-facilitators reflect on what

occurred with respect to the clients—themes, participation level,

critical issues—and what they noticed each other do and the

response from clients. This provides them with the opportunity to

notice how their skills are developing and the impact their strategies

are having on the group. The clinical supervisor shares what

she was thinking during the group that influenced what she said

or did not say. After the clinical supervisor has modelled this

process, the staff member does the same, which expands the

opportunity to discuss what he or she did and did not do and the

reasons underlying interventions. The co-facilitators discuss what

their follow-up will be in the next session and the cycle continues.

The clinical supervisor invites her co-facilitator to risk trying a

strategy that the clinician had thought about, but had not done.

Within the Keeping Safe Group, staff members learn that even

though it theoretically makes sense for the program’s clients to

have safety plans, the process goes beyond ensuring that clients

have completed these plans. Staff members need to be open to

40


eflecting on the barriers that clients experience, speaking about

what prevents them from being able to follow through on using

their plans, and helping clients process their resistance as

opposed to getting into a power struggle with them.

Role playing

After the clinician describes a challenge he or she is encountering with a client, the

clinical supervisor can suggest a role play where the clinician and clinical supervisor

act out the situation where the clinician had trouble. For example, if the clinician

plays the role of the client, the clinical supervisor can show the clinician other ways

of responding to what the client is saying. The roles can be reversed, with the supervisor

taking on the client role. This variation requires that the supervisor has enough

information about the client’s responses to be able to respond meaningfully. The

supervisor can see how the clinician responded to the situation in question and then

give feedback.

Reviewing taped sessions

Ongoing Clinical Supervision

The clinician is asked to either audio- or videotape the session or sessions with a

client. The clinician must ensure that the client understands that this is being done

to help the clinician provide optimal care. After this has been explained, the clinician

must obtain written consent from the client. The clinician reviews the tape and

marks the segment that he or she would like to discuss with his or her supervisor.

The clinician plays this segment during the session and the clinician and clinical

supervisor discuss their observations. The clinician may first be asked to talk about

what he or she was thinking and feeling at the time and how these thoughts and

feelings contributed to what he or she did or did not say.

CULTURAL COMPETENCE AND DIVERSITY

Influence of privilege and oppression

in the therapeutic relationship

Skilled clinicians possess knowledge and understanding about how oppression, racism,

discrimination and stereotyping affect them both personally as well as in their work.

They are knowledgeable about how sociopolitical influences impinge on the lives of

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Clinical Supervision Handbook

people who are marginalized because of race, culture, gender, sexuality, age, language,

religion and abilities. Without this awareness, clinicians can respond to their clients

with a range of feelings such as anger, defensiveness, sadness and powerlessness, and

miss opportunities to explore how these life experiences have contributed to the

client’s mental health and addictions. The Wheel of Intersecting Axes of Privilege,

Domination and Oppression (see Figure 1, p. 43) is a tool that can be used to help

clinicians raise their awareness in this area as they plot themselves along the various

axes and consider where their clients are located as well. This helps to identify where

there might be tensions in the clinician-client relationship due to meanings that

either person may attribute to specific incidents within the relationship based on life

experience. This tool also facilitates the exploration of contextual factors that are

important to consider as the clinician assists the client in his or her recovery. For

example, a client is not open about her sexual identity as a lesbian. Keeping this

hidden influences her relationships with others resulting in shame, guilt, depression

and anxiety. She drinks to cope. The clinician assumes the client is heterosexual

and thus misses a key issue that has contributed to the client’s mental health.

Using the tool

Introduce the tool to clinicians by explaining the rationale for its use, as described

above. Then ask the clinicians to take some time and put an “X” on each axis at the

point that represents where they see themselves. If this exercise is done in group clinical

supervision, tell the clinicians that they are not required to share the details with

the group. After they have completed the exercise, ask them what they noticed—did

anything in particular jump out for them? Many people are surprised at the number

of axes and how they experience greater privilege in some areas as opposed to others.

Next, ask the clinicians to think about the clients they currently see and to place

them on all of the axes based on what they know about them. Then ask how they

think their experiences and those of their clients might influence their relationship

with one another. For example, the clinician is a Caucasian, well-educated woman,

middle class, married, with two children. Her client is a single, black woman, making

enough money to pay her bills, raising three young children on her own. She did not

complete high school. She has been involved in the sex trade as her main source of

income to support herself and her children. She uses alcohol and marijuana to cope

with her feelings, and the experience of having been sexually abused in childhood

by her father. Based on the clinician’s experience and biases, she or he may not raise

questions about how racism and childhood sexual abuse may have contributed to

dropping out of school, having limited employment opportunities due to discrimination

and an overall poor sense of self.

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Ongoing Clinical Supervision

FIGURE 1: THE WHEEL OF INTERSECTING AXES OF PRIVILEGE,

DOMINATION AND OPPRESSION

Source: From A., Diller, B. Houston, B., Morgan, K.P. and Ayim, M. (1996).The Gender Question in Education: Theory,

Pedagogy, and Politics. Boulder, CO: Westview Press. Reprinted with permission.

43


Questions for reflection

In addition to using the diagram, clinicians are asked to consider the following

“Questions for Reflection” to further explore what influences their perceptions of the

client in addition to experiences of privilege and oppression. Through this exercise,

the clinical supervisor helps the clinician to break through stereotypes; acknowledge

his or her beliefs and values; and understand how stereotypes, beliefs and values can

be barriers to understanding the client’s experience. The exercise may raise new

issues for discussion with the client (e.g., asking about experiences of discrimination,

and what it is like for them having a therapist who is from a different culture, race).

These questions were developed by Donna Akman, PhD, CPsych, and Cheryl

Rolin-Gilman, rn, mn, cpmhn(c), Women’s Program, Centre for Addiction

and Mental Health.

A Thoughts/feelings about client/session:

• What am I puzzled by with this client/situation?

• What occurred in the interaction with this client?

• What were my thoughts and feelings?

B Personal/social location:

• What is my personal/social location with respect to this client,—i.e., along continuum

of privilege to oppression—(race, gender, language, sexuality, race, ability, education,

age, fertility, European in origin vs. non-European, Aboriginal, attractiveness,

colour, etc.)?

C Observations/reflections about session:

• What did I learn from observing/reflecting on my experience? What are the

essential aspects that I am aware of?

• What are alternative methods of action that I can take with my understanding?

D From the questions below, choose one that you would like to discuss:

• What factors influenced my response in this situation?

• What was I trying to achieve?

Clinical Supervision Handbook

• How were others feeling? How did I know this?

44


• Does this situation connect with previous experiences I have had?

• How do I feel about this experience?

• What were my hopes for the outcome of this incident?

• How were my hopes related to my own expectations?

• What are the sources of my knowledge in my life and work?

• What are the sources for my ideas and values?

• To what extent were social norms or expectations (including organizational)

operating in this incident?

Adapted from: Johns, C. (2000). Becoming a Reflective Practitioner: A Reflective and Holistic Approach to Clinical

Nursing Practice Development and Clinical Supervision. Oxford, England: Blackwell Science.

Tate, S. (2004). Using critical reflection as a teaching tool. In S. Tate & M. Sills (Eds.), The development of critical

reflection in the health professions. Occasional paper (4). Learning and Teaching Support Network (LTSN) Centre

for Health Sciences and Practice, (pp. 8–17).

GROUP SUPERVISION

Ongoing Clinical Supervision

Although the literature tends to focus on individual clinical supervision, given time

and budget constraints, clinicians will probably be more exposed to group supervision.

The following is adapted from a series of studies on group supervision conducted

by Bogo, Globerman and Sussman (2004a).

In group supervision, a group of clinicians meet on a regular basis with one supervisor.

Group supervision allows clinicians to present examples of their practice and, through

discussion, learn from exposure to a wide range of ideas and perspectives offered by their

supervisor and peers. Through peer interaction, clinicians can develop a more accurate

self-appraisal of their ability and learn about group process and group dynamics.

Groups can function in different ways. Examples include rotating case presentations

or focusing on particular topics and their relationship to the therapeutic relationship

(e.g., working with clients with a trauma history, stage-oriented trauma treatment).

Novice clinicians have the opportunity to learn from experts. Experts develop by

demonstrating their ability to self-reflect. They do this by bringing their experiences

of their clients to the group, and by sharing their thought processes as they discuss

the questions they have asked themselves in order to better understand the choices

they made in response to their client’s behaviour. They talk about the connection

they make between theory and similar situations they have encountered with other

45


clients, illustrating where they have been able to generalize an approach and where

they have had to make modifications.

Purposes of group supervision

Group supervision provides opportunities for clinicians to learn skills in peer supervision

and to experience support from colleagues who may be struggling with similar

feelings around caring for a challenging client. Group supervision can also contribute

to team cohesiveness and provide a rich experience for exploring several different

perspectives. Group supervision may be more feasible than individual clinical supervision,

particularly on a busy inpatient unit where taking time away to meet oneto-one

may not always be practical. It may also be a desirable method of supervision

with reduced resources.

Successful group supervision

Group supervision is most successful when the supervisor is available and supportive,

and regular scheduled sessions are offered that are flexible in duration and protected

from interruptions. Supervisors can show support by demonstrating respect for

the supervisees, by not minimizing their opinions, and by allowing them to make

mistakes. Successful group supervision is highly dependent on the supervisor’s ability

to assist group members to process group dynamics, especially when they interfere

with sharing practice and learning issues.

Leadership style

Clinical Supervision Handbook

Clinical supervisors need to provide staff with an orientation to group supervision.

Staff members must feel safe (i.e., not feel embarrassed, shamed or sense that others

are competing with them to be the “best clinician”) and understand what is expected

of them. They should also be asked what they expect from the group and the supervisor.

The clinical supervisor should ensure that both content and process issues are

addressed. Clinical supervisors model expected behaviour of a group member and

provide feedback in a way that focuses on the clinician’s strengths rather than his or her

mistakes. They intervene when group members’ behaviours do not support the norms

of risk-taking and providing constructive feedback. For example, in the case of a

clinician who does not discuss difficulties that she or he has working with clients,

tending instead to focus on questioning others about their practice, an intervention

46


y the clinical supervisor might be to ask the clinician if he or she ever experiences

what other group members are discussing (e.g., similar feelings in response to client

behaviours) and how the clinician dealt with these feelings when they arose. Clinical

supervisors provide equal opportunity for each clinician to participate, rather than

favouring one clinician over others.

Benefits of group supervision

Group supervision:

• allows for learning from other clinicians’ interactions with clients; from the

diverse backgrounds and experiences of both clinicians and clients; and from

different perspectives on issues

• provides opportunities for reflection and discussion with others—hearing how

others reflect on their work, including the kinds of questions they ask

• examines the relationship between theory and practice

• helps clinicians learn about group dynamics

• allows clinicians to practice new behaviours

• demonstrates the universality of concerns, such as, “I am not the only one who

thinks they do not know what they are doing” or “I am not the only one who is

feeling hopeless about this client situation”

• helps clinicians develop more accurate self-appraisals.

Obstacles to productive group supervision

Learning is compromised when some or all of the following occur.

Content issues

Ongoing Clinical Supervision

• There is too much focus on administrative issues such as scheduling

and procedures.

• Not enough time is spent reviewing clinical issues.

• Too much time is spent sharing information rather than on reflection and dialogue.

Process issues

• Group supervision turns into individual supervision with an audience (i.e., clinicians

place themselves in a vulnerable position by disclosing their struggles while the

47


est of the team says nothing and the supervisor only focuses on the presenting

clinician).

• The supervisor does not process feedback from others (i.e., no one ties feedback

together or links to others’ experiences).

• Clinicians feel overly criticized.

• Clinicians feel others are not taking risks.

• A lack of open communication impedes group cohesion.

• The clinical supervisor shares conflicts with staff, personal issues or his or her

own frustrations about clients in a non-professional manner.

• Conflicts occur with team members who are attending the supervision and others

who are outside of the group. (It is helpful to have strategies to address this within

the group.)

Importance of trust and safety in group supervision

The development of trust and safety may be impeded when a member of the group

takes on the role of “consultant” (i.e., the person who is never listening, always “one

upping” other team members, or giving an answer or suggesting a “better” approach).

For example, group members who do not take risks, who only present the cases

they are not having difficulty with and do not reflect on their own practice in group

supervision tend not to bond with the group. Trust and safety in the group may be

compromised when the members vary significantly in their approaches to practice,

and/or when members come from a variety of disciplines with varied levels of

experience.

Open vs. closed group

Clinical Supervision Handbook

Providing group supervision on an inpatient unit with an interdisciplinary team

requires some flexibility due to nurses’ schedules. Having a closed group requires

nurses to come in on days off. Open groups accommodate a variety of schedules.

However, they present other challenges.

In an open group, participants may be reluctant to self-disclose. How much a clinician

chooses to self-disclose often depends on the cohesion of the group as a whole and the

mix of staff attending the group that day. Closed groups can achieve a greater sense of

cohesiveness and safety, making it easier for staff members to expose their vulnerability.

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Ongoing Clinical Supervision

Other disadvantages of open groups include an absence of focus and the need to

repeat content. In a closed group, clients can be discussed over time, with more

opportunities for clinicians to report on results of following through on recommendations

and the insights that emerge during group clinical supervision. When the

group is open, this kind of continuity is more difficult. The clinical supervisor needs

to deal with the needs of the group generated by the most emergent needs of clients

currently on the unit.

Five tips to successful open-ended groups

1. Review group norms for every group meeting and have a handout

available that outlines the norms.

2. Offer group members an opportunity to provide a case outline

for any ongoing case.

3. Obtain feedback from all staff on a regular basis both from

those who attend and those who do not to assess the effectiveness

of the group.

4. Ensure that there is a focus from group to group relevant to all

participants and be prepared with potential topics for discussion

(e.g., ethical dilemmas), should the group have difficulty

identifying a focus.

5. Avoid repetition of content because group members who

attend regularly may get bored and frustrated.

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Strategies to promote group cohesion

Structure

Clinical Supervision Handbook

• Teach group skills and how they relate to group rationale and goals for group

supervision.

• Clarify purposes of the group (informational, educational, administrative).

• Explain how clients will be discussed, group norms, structure, how feedback will

be given and received, how time is shared, how conflict and competition in the

group will be handled.

Group process

• Encourage open communication about current and immediate issues among

group members, such as group tensions.

• Intervene to ensure that group norms are respected.

• Provide leadership by modelling and identifying facilitative group member

behaviours, such as risk taking, and providing constructive feedback.

• Facilitate focused discussion and feedback.

• Provide supportive and helpful feedback.

• Ensure that feedback about practice is balanced and focused and propose

possible next steps.

• Encourage team members to respond to each other’s concerns in a positive

manner.

• Ask direct questions regarding clinician’s experiences if soliciting ongoing group

feedback is a challenge, such as “sometimes clinicians can feel overly criticized

in group supervision. Are any of you having that experience in this group?”

This targeted feedback may encourage more group level disclosure because it

normalizes clinicians’ concerns.

• Validate different perspectives and approaches and stages of learning.

• Rework formative stages of group process.

• Discuss what is and is not working in the group process.

• Provide time for critical reflection on practice and integrate theory and practice

in each session.

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Ongoing Clinical Supervision

Yalom’s therapeutic factors and group supervision

• Yalom’s therapeutic factors are listed below and described in relation to the experience

of being a member of a supervision group:

• Instillation of hope: Within the context of group supervision, clinicians get a

sense that there is light at the end of the tunnel when working with challenging

clients. Hearing the experiences of others can highlight progress that the presenting

clinician might have lost sight of because he or she has lost some objectivity.

• Universality: A sense that clinicians are not alone in the work they are doing and

how they are feeling. Feeling validated from other clinicians who discuss similar

experiences with clients.

• Imparting of information: Providing information to others about the client, how

to work with them or the process of self-reflection.

• Altruism: Having the opportunity to help other staff.

• The corrective recapitulation of the primary family group: Traumatic re-enactments

play out in the team based on the clients projected experiences, power differentials

within the team and how these are processed, parallel process and how conflicts

are managed within the team.

• Development of socializing techniques: Learning how to communicate with one

another within the team using interpersonal feedback and constructive feedback

without judgment.

• Imitative behaviour: Learning how other team members work with clients and

each other by observing what they say and do in supervision.

• Catharsis: An opportunity to vent and label feelings.

• Existential factors: Issues that come from the person’s confrontation with the

“ultimate concerns of existence”: death, freedom, isolation and meaninglessness.

In working with clients, a significant existential issue that clinicians encounter

over and over again is human suffering. Having an opportunity to process these

issues is helpful to clinicians who may otherwise feel overwhelmed.

• Cohesiveness: The sense of belonging and value within the team.

• Interpersonal learning: How the team interacts with one another in the here

and now while discussing a client can be a reflection of the client’s relationships

in the world outside (e.g., staff that takes on the negative aspects of the clients,

those who are the vessels of the positive) (Yalom, 1995).

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Clinical Supervision Handbook

An example of group clinical supervision

We find that the clinicians’ experience is most helpful and safe when it is structured

in such a way that the expectations of all participants and what is expected of the

participants are clear. This allows them to come to the sessions prepared, understanding

their roles in the context of the person requesting assistance and giving

constructive feedback to others.

CASE EXAMPLE: GROUP CLINICIAN SUPERVISION

The clinician begins by presenting a clinical dilemma in the form

of a question so the group has a frame of reference before hearing

about the client. An example of this would be, “I would like

your help with the client I am going to present. I am feeling stuck

and would welcome your ideas about how to help the client consider

some other alternatives.” Another example might be, “This

client is feeling overwhelmed with many stressors in her life. She

isn’t working. Her kids are a handful for her. She does not feel

safe where she is living. She continues to have flashbacks and

nightmares. When I listen to her, I don’t know where to start.

I feel overwhelmed myself. I would welcome your ideas.” The purpose

of introducing this question is to keep the feedback focused,

diminishing the possibility of a “free-for-all.” Other clinicians

might ask several questions that do not address the needs of

the clinician and assume the clinician has not already covered or

considered what is being asked. After the question / dilemma

is put forward, the clinician presents some background on the

client (e.g., major concerns, history of her or his work with

the client, attempted solutions—material that directly relates to

the question).

As the clinician receives feedback from the group, he or she takes

notes and then shares what most stands out and what specifically

was gleaned from the consultation. The clinician then discusses

what she or he would like to try and how it might be helpful. The

clinician will then make a note of this recommendation in the

progress note or on the Interdisciplinary Plan of Client Care.

In a round table format, each person is invited to ask one question

of the clinician once he or she is finished providing the overview.

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Ongoing Clinical Supervision

Individuals may pass if they do not have a question. Specific

questions are intended to help the other consultants develop an

understanding of the client. The clinician provides brief answers

to the questions and makes a special note of questions he or she

cannot answer, as these may be keys to future possible solutions

to consider. Examples of questions could be, “What happens

when you suggest the strategies that you have with your client?”

“Do you know if she has had similar experiences within other relationships?”

“Do you know about the community resource that

can help her with…?” If individuals wish to do a second or third

round of questioning (depending on the size of the group), they

may do so, again with options to pass. The discussion is opened

up to everyone, and ideas offered in a spirit of curiosity. This is an

important point to emphasize so that clinicians don’t feel as

if their colleagues are attacking them or that the questions are

coming from a place of judgment and competition rather than a

desire to be helpful.

INDIVIDUAL CLINICAL SUPERVISION

Individual clinical supervision is the most widely used model of clinical supervision

in social work practice (Kadushin & Harkness, 2002), and has been described by

nurses as a valuable process providing the time to reflect on and learn from their

practice (Teasdale et al., 2001; White et al., 1998). Nursing best practice guidelines

for establishing therapeutic relationships recommend the provision of clinical

supervision to support the establishment of therapeutic relationships between

nurses and clients (rnao, 2002). Clinical supervision is an opportunity to help and

support clinicians to reflect on clinical dilemmas, challenges and successes; and to

explore how they responded to, solved or achieved them (Cutcliffe & Lowe, 2005).

It is a forum for considering the personal, interpersonal and practical aspects of

care to develop and maintain clinicians who are skilled and self-reflective (Cutcliffe

& Proctor, 1998).

In individual clinical supervision, concepts crucial to the development of therapeutic

relationships with clients, such as trust, respect, empathy, empowerment and a nonjudgmental

approach are understood by developing a trusting, supportive relationship

with a clinical supervisor. The supervisory process is like a journey as clinical supervisor

and clinician explore clinical material together, with a view to arriving at a deeper,

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Clinical Supervision Handbook

more meaningful understanding of the client. In this way, the supervisor-clinician

relationship parallels the clinician-client relationship.

Beginning individual clinical supervision

The first task of the clinical supervisor is to create a safe space in which the clinician

can re-experience clinical difficulties and the feelings associated with them. Creating a

safe space and a supervisory alliance with the clinician involves developing a trusting

relationship and providing education regarding clinical supervision: what it is and

how it works (Gallop, 2004). This is particularly important because clinicians will

bring their own perceptions of clinical supervision to the supervisory relationship.

Exploring previous experiences with clinical supervision and the feelings associated

with these will provide an opportunity to correct any misconceptions that the clinician

has about the supervisory process. Even if the clinician has not had clinical supervision

before, it will be important to explore preconceived notions about it. The word

supervision itself may conjure up negative feelings, particularly from nursing staff

where historically, it was associated with management and surveillance. On the other

hand, social workers view clinical supervision as a crucial component of their practice.

Education regarding supervision should also establish clear boundaries by not only

addressing what clinical supervision is, but also addressing what it is not; for example,

clinical supervision is not personal therapy. The focus is on the clinician-client

relationship. Having said that, there may be times when personal issues are having

an impact on the clinician-client relationship and this needs to be acknowledged.

A safe space is further constructed by scheduling regular time to meet with the clinician

in a private place, such as the supervisor or clinician’s office. Scheduling a minimum

of 45 minutes to one hour every four weeks for individual clinical supervision is

recommended in the nursing literature (Butterworth et al., 1997; White et al., 1998)

while social work supervision is usually provided weekly or every second week.

Winstanley and White (2003) note that clinicians in monthly or bimonthly sessions

scored higher on the Manchester Clinical Supervision Scale (Winstanley, 2000), a scale

that measures the effectiveness of clinical supervision. Supervision time is protected,

uninterrupted time that both clinical supervisor and clinician respect. The clinical

supervisor demonstrates his or her availability, consistency, respect and reliability

by being present and punctual, which not only serves to establish a trusting, safe

relationship with the clinician but also models qualities that clinicians ideally transfer

to their clinical practice to build therapeutic relationships with their clients. Some

clinicians may be reluctant to engage in scheduled supervisory sessions or may feel

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Ongoing Clinical Supervision

they cannot take time away from a busy inpatient unit. These clinicians may prefer

more informal support at least as a starting point to building trust and engaging in

more formal clinical supervision (see Spontaneous Supervision, p. 66). Additionally,

engaging inpatient nursing staff in particular in individual clinical supervision can

be challenging due to unit constraints (see Nursing and Clinical Supervision, p. 75).

Confidentiality is critical to the development of a safe and trustworthy environment.

The clinical supervisor explains that discussions in the sessions are confidential. The

only time this confidentiality is broken is if the clinician has been involved in unsafe

or unethical behaviour with a client. The supervisor must confront such behaviour.

Ideally, the supervisor helps the clinician identify the problem and initiate corrective

action. The supervisor monitors the process (Gilmore, 2001). If supervision has been

mandated, the supervisor is obligated to share information with the manager. (See

When Clinical Supervision is at the Request of the Manager, p. 28). A strong confidential

ethic contributes to a safe environment. Without the establishment of a safe

environment, the clinical supervisor and clinician will be less likely to explore the

more risky aspects of unprofessional practice (Epling & Cassedy, 2001).

A discussion of goals is important to the development of a focus for clinical supervision

sessions (see Beginning of the Relationship and Contracting, p. 23). Clinicians

may come with very specific goals, such as addressing difficulties experienced while

caring for a particular client, a client population or diagnosis, or they may require

assistance in exploring and developing their goals within a framework of clinical

supervision. Frameworks or models of supervision within both nursing (Proctor,

1991) and social work (Kadushin, 1976) frequently include the components of

support, education/learning and administration, and supervision is described as a

reflective process (see Appendix 1, a review of the literature, pp 103). It is important

to note, as Fowler and Chevannes (1998) suggest, that some clinicians may not be

ready to or able to cope with intense examination of themselves and their work. If the

clinician is inexperienced clinically, then a focus on reflection may not be appropriate,

at least not initially. A more directive approach such as a preceptorship may better

meet the clinician’s goals, with clinical supervision being available when the clinician

is more experienced.

The opportunity to off-load in the context of a supportive relationship builds trust

and a foundation for later exploring clinical material in more depth. Caring for

clients living with mental illness and/or addictions is hard work. Listening to clients’

stories and bearing witness to their pain and suffering can take a toll on clinicians

and contribute to burnout and low morale. Novice clinicians may be particularly

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Clinical Supervision Handbook

vulnerable to feeling alone and overwhelmed. An affirming and empathic supervisory

experience can enhance morale and increase self-confidence. It provides a starting

point, and a strong foundation in which the clinician feels safe, supported and gradually

is able to take more risks within the relationship. Similarly, this opportunity to

off-load and receive support is critical in the development of a therapeutic alliance

with clients. In this way, the supervisor-clinician relationship mirrors the clinicianclient

relationship as an experience of feeling comforted and understood.

The working phase of individual clinical supervision

Once a trusting, safe foundation is established, the clinical supervisor and clinician

begin the process of exploring and understanding thoughts and feelings, such as

those experienced by the clinician toward the client, and the client toward the clinician.

Developing a deeper understanding enables the clinician to respond in a less

emotionally reactive and more conscious, thoughtful manner to the client (Gallop,

2004). Ideally, it is the clinician or the supervisor-clinician dyad that arrives at this

deeper understanding of a particular client situation. If this doesn’t happen, the clinical

supervisor may need to take a more directive approach at least in the earlier

stages of supervision. The process of journeying together is modelled by the clinical

supervisor, as illustrated in the vignette below, and is empowering to the clinician. In

the clinician-client relationship the therapist models a similar process of journeying

with the client, as issues are explored and better understood.

Part of the journey includes the development of self-awareness in the clinician and a

recognition that his or her own experience is influenced by multiple factors such as

race, culture, health, socio-economic conditions, gender, education, early childhood

experiences, current relationships, beliefs and so on. With the development of this

self-knowledge the clinician is better able to distinguish between her own experience

and values, and those of her client. “In this way, she is able to appreciate the unique

perspective of the client, is able to avoid burdening the client with her issues, and

can prevent imposing her own beliefs and preferred solutions upon the client”

(rnao, 2002).

The following example illustrates some of the concepts discussed so far.

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Ongoing Clinical Supervision

CASE EXAMPLE: A NURSE IN INDIVIDUAL

CLINICAL SUPERVISION

A nurse on an inpatient unit met with her supervisor to discuss a

client with whom she was having difficulty engaging. This client

had a chronic mental illness and also suffered from diabetes. The

nurse described her interactions with the client and talked about

how she was focusing on the client’s diabetes, which was not well

controlled, and her mental illness. She herself felt as though she

was “nagging” the client “all the time” about the importance of

following a diet to better control her diabetes. The client became

withdrawn and uncommunicative in her interactions with the

nurse. The nurse said she had reached an impasse with this client.

The clinical supervisor explored the nurse’s feelings, as well as

how the client may have been feeling. The nurse felt like a

“nagging parent,” constantly pointing out to the client what she

ought to be doing. She cared for the client and was fearful that the

client’s health would deteriorate further, and she would never get

better if she did not adhere to her dietary and treatment regime.

She also felt a sense of urgency and responsibility, given her timelimited

involvement with the client as an inpatient nurse. If the

client didn’t get better, she wasn’t doing a good job. The client,

she thought, may have felt powerless, frustrated and tired of

“being a patient.” The nurse and the clinical supervisor began to

wonder if her focus on the client’s illness was interfering with her

seeing the client as a whole person and with getting to know her,

beyond her illness. Perhaps that is why the client had withdrawn.

Together they explored an empathic perspective and tried to see

and feel the world as her client was seeing and feeling it. They

wondered: what was it like for her to be ill and in hospital? How

did it feel for her to have so much of her life revolve around “being

a patient”? How did it feel for her to be dependent on others for help

indefinitely? By trying to experience the client’s world from her

perspective, they came up with an intervention aimed at helping

the nurse reconnect with her client. This involved taking the client

off the unit, perhaps for a walk or to the coffee shop (the client

would decide on the activity) in a “less illness” focused context

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Clinical Supervision Handbook

and trying to engage her around non-illness related topics—getting

to know her as a person, her hopes, her dreams, her interests,

her past and so on.

For the next four weeks, the nurse did this. When the clinical

supervisor met with the nurse again she described the process

and outcome. The client chose the coffee shop and they made a

point of going there to “chat” at least once a week. The nurse

refrained from discussing the client’s illness during these outings,

and instead explored topics of interest to her client—they talked

about what her life was like before she became ill, how she liked

to dress and wear her hair; and her dream to work as a hair stylist.

These outings to the coffee shop became important to the client

and she looked forward to them. The nurse noticed that over the

course of the next four weeks, her client became much less defensive

with her on the unit, and more relaxed. She started to pay

more attention to her dress and her appearance. Eventually she

was receptive to the nurse addressing her illness issues again.

When the client was discharged from the hospital she gave the

nurse a coffee mug. The clinical supervisor and nurse discussed the

significance of this, an affirmation that these trips to the

coffee shop had been meaningful to the client and had contributed

significantly to them working together therapeutically to

achieve a positive outcome.

This clinical situation highlighted for the nurse the limits of her

role and resulted in her understanding more clearly that she

could not “control” the client. By taking a holistic approach to the

client, getting to know her beyond the illness, she communicated

respect for her client as a person, understanding and a hopefulness

that facilitated the therapeutic relationship and contributed

to the client’s recovery. This example demonstrates how concepts

such as holistic care, empathy and recovery are woven into the

supervisory process. For the nurse, these concepts are brought to

life and more deeply understood as they are experienced in the

context of a real therapeutic relationship.

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Ongoing Clinical Supervision

Another example highlights the concept of empathy and its role in developing therapeutic

relationships.

CASE EXAMPLE: A CLINICIAN IN

INDIVIDUAL CLINICAL SUPERVISION

A clinician was providing care to an outpatient, a young woman

who was recovering from a first episode of psychosis. All

attempts to engage her in a dialogue about the illness and discuss

the need for ongoing medication had failed. The client

would “shut down” and repeat very defensively that she was fine

and she didn’t need to talk about this.

When the clinician met with her clinical supervisor, she shared

her frustrations about the client not being receptive to her health

teaching and education about her illness. The clinical supervisor

acknowledged her frustration and explored her feelings, further

revealing the clinician’s concerns about this client becoming ill

again if she did not develop insight into her illness. Together, they

stepped back and tried to look at the situation from the client’s

perspective. The clinical supervisor asked the clinician to tell her

more about this young client. The clinician described a young

woman who had just experienced a first episode of psychosis.

She had been functioning well prior to the illness, attending

university and had lots of friends. She had to take time off university

to recover from her illness, and felt cut off from her friends. The

clinician and clinical supervisor talked about how the client now

had to come to terms with having suffered a highly stigmatizing

illness that had significantly interrupted her life. They talked

about the implications of her illness, which included an uncertain

future. Together they arrived at a more meaningful understanding

of what might be going on inside this young woman.

The next time the clinician met with her client the following interaction

unfolded:

Clinician: “I’ve been thinking about our meetings and have realized

that I’ve been talking a lot about the importance of medication in

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preventing further illness episodes. And I’ve noticed that isn’t of

much interest to you right now.”

Client: nodded her head in agreement

Clinician: “I’m wondering how you’re feeling about this illness

right now (pause) and I’m thinking that it must really suck. It’s

really interrupted your plans.”

Client: Tears start to well up in her eyes as she says angrily, “I hate

it. I don’t want to take medication. I don’t want to be sick. Why

can’t things just be the way they were before? It’s just not fair!”

Clinician: “Yes. You’re right. It’s not fair. It’s awful when something

disrupts your life like this, especially an illness. I can understand

why you feel so angry and sad and just want it all to go away.

Client: nods and begins to weep.

This vignette illustrates how an empathic approach allowed the clinician to attend to

the subjective experience of the client and validate that her understanding was an

accurate reflection of the client’s experience. She gained entrance to the client’s inner

world and was able to better understand the client’s experience. The result was a

strengthening in the bond between the clinician and client as the client felt the comfort

of being understood. This interaction opened the door to addressing the client’s

experience of illness and the meaning it had for her. The client no longer felt that

the clinician was “pushing” her agenda onto the client. Eventually, the client was able

to negotiate with the clinician and her psychiatrist a medication regime that she the

client felt comfortable with.

Boundaries

Clinical Supervision Handbook

Clinicians have an obligation to put client needs before their own and to act in the

client’s best interests. “Sometimes, our own conscious or unconscious wishes make

it hard to recognize boundary violations” (rnao, 2002). A very important function

of individual clinical supervision is the development in the clinician of an awareness

and understanding of the boundaries and limits of the professional role. This understanding

of boundaries is crucial to providing safe and ethically sound clinical

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Ongoing Clinical Supervision

practice. Within a safe and trusting relationship, the clinician can explore the client’s

thoughts and feelings related to the client, and discuss behaviours that may indicate

the crossing of boundaries, such as spending extra time with clients, having special

clients, or doing activities with clients that the clinician does not share with colleagues.

In this way, clinical supervision is a proactive process that can prevent boundary

transgressions. Proctor (1991) refers to this function of clinical supervision as “normative.”

Normative supervision is concerned with promoting high quality care and

reducing risks. The supervisor is obligated to confront any situation or practice he

or she feels is unethical or unsafe. As mentioned previously, an ideal process is one

in which the supervisor facilitates the clinician to identify the problem and initiate

corrective action.

Transference, countertransference and parallel process

As supervision moves beyond the initial stages of developing trust and safety, a more

in-depth understanding of the client is achieved by exploring the processes of transference,

countertransference and parallel process. Transference refers to a process in

which the client transfers past or present attitudes and feelings toward family members

or other important persons in their life onto the clinician. It may be positive or negative

and, in classic psychoanalytic literature, is described as an unconscious phenomenon.

Clients may repeat interaction patterns characteristic of earlier relationships in their

relationship with the clinician. The client’s transference is important to explore with

the clinician as it contributes to greater understanding of the client’s difficulties. For

example, one might speculate that the client in the first vignette developed a negative

transference toward the nurse responding to her like a critical parent may have in

the past. The nurse, feeling as though she was “nagging” the client, and the client’s

subsequent withdrawal from the relationship, supports this notion.

Countertransference refers to thoughts and feelings experienced by the clinician toward

the client. Countertransference may also be experienced by the supervisor toward

the clinician, and by the clinician toward the supervisor. Similar to transference, these

feelings may be positive or negative. Before any exploration of countertransference,

it is crucial that there be a trusting relationship between clinical supervisor and

clinician. The clinical supervisor must also be cognizant of maintaining the boundaries

of the supervisory relationship. “The guiding principle is that all discussion

relates to the client. If the supervisor or supervisee sees a drift towards exploration

of factors relating to the supervisee’s relationships and life apart from reactions

to and feelings about the client, the supervisor should stop, rethink, and consider

alternatives.” (Falender, 2006, p. 39)

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Clinical Supervision Handbook

Parallel process refers to changes in the supervisor-clinician relationship that relate

to dynamics in the clinician-client relationship; in other words, it involves a series

of transference-countertransference interactions. The supervisor needs to be alert to

changes in the clinician’s mood or behaviour, as well as feelings within him- or herself.

Such changes may indicate that a parallel process is taking place (Gallop, 2004).

Grey and Fiscalini (1987) note that the motivation for the clinician engaged in parallel

process with the clinical supervisor is that by acting like his client he is trying to

communicate information not consciously accessible, or that he is trying to see how

the clinical supervisor would handle the situation.

An example is described in the following vignette.

CASE EXAMPLE: TRANSFERENCE AND

COUNTERTRANSFERENCE

A social worker was involved with a client on an inpatient unit,

and his wife. He described to the clinical supervisor the conflict

this couple was experiencing and the events that led up to a

restraining order being issued by the court prohibiting the husband

from having any contact with his wife. This followed a physical

assault by the husband. The social worker described his experience

of working with this client and the couple. The husband

and wife, although physically apart, continued to communicate

indirectly through the social worker. He found himself in the role

of intermediary between the wife and the husband. As the social

worker described the relationship and his involvement as an

intermediary, the supervisor began to find it difficult to follow.

She had to frequently seek clarification from the social worker as

his communication became increasingly convoluted and she

becoame increasingly confused. She shared her confusion with

the clinician and asked if this was how he was feeling in his work

with this couple.

This led to a discussion of the social worker’s role with this couple,

including the boundaries of his role, and the couple’s conflict,

ambivalent feelings and hidden agenda that seemed to be getting

played out through the social worker. Afterward, the clinician felt

less burdened and was able to focus more clearly on the boundaries

of his role with this couple and set clear limits. He also

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ecognized the limitations of his professional involvement and

more clearly understood what could realistically be achieved with

this couple during a brief inpatient stay.

Authority and dependency issues are frequently at the root of parallel processes

(Grey & Fiscalini, 1987). If the clinical supervisor and clinician don’t explore

motivations for engaging in this process, they may get stuck in a series of transferencecountertransference

interactions. Grey and Fiscalini (1987) state that this is avoided

if the clinical supervisor empathizes with the clinician, but does not get stuck in

the empathic process. The clinical supervisor is able to see the client and clinician’s

perspectives, and differentiate them from his or her own. The supervisor is then able

to clarify the transference-countertransference interplay occurring. However, if the

clinical supervisor does get caught up in a parallel process, he or she can use his or

her own emotional response to explain the anxiety in the clinician-client dyad and,

additionally, the anxiety in the supervisor-clinician dyad.

Exploring transference, countertransference and parallel process as they emerge

within the supervisory relationship and clinician-client dyad ultimately illuminates

a deeper, more meaningful understanding of the client.

Conclusion

Ongoing Clinical Supervision

Individual clinical supervision, when conducted in the context of a supportive, trusting

relationship, is a vital process that contributes significantly to quality client care.

As the clinician’s capacity to engage in reflective practice grows, so too does his or

her ability to establish therapeutic relationships with clients. The supervisory process

is a journey that clinical supervisor and clinician embark on together. It is a journey

that in so many ways models the clinician-client relationship by introducing experientially

concepts critical to the development of healthy and therapeutic relationships

with clients such as empowerment, empathy, trust and boundaries. The supervisory

process and the client are better understood through discussions of transference,

countertransference and parallel process as they emerge along the way. While taking

time out of one’s busy schedule to participate in or conduct clinical supervision

may at times seem challenging, this is time well spent, particularly when one sees

the positive outcomes for clients, the therapeutic impasses that are overcome, and

the boundary transgressions that are avoided.

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A CASE PRESENTATION MODEL

FOR CLINICAL SUPERVISION

Presenting a case to a supervisor and / or colleagues helps clinicians organize information

about treatment into coherent themes and concepts. It also gives the clinical

supervisor a chance to evaluate which areas of practice and client management the

clinican has mastered and which could be improved or enhanced (Ask & Roche,

2005) There are many ways that case presentations can be structured. The following

section describes the approach used by one camh program.

Using the Core Conflictual Relationship Theme

The clients of a camh program that provides inpatient and outpatient transitional

care treatment for women with a mood disorder associated with a history of interpersonal

trauma (childhood and/or adulthood physical, emotional and/or sexual

abuse often experience the consequences of trauma including substance abuse, selfharm

behaviour and dysfunctional interpersonal relationship patterns. Because they

experience these problems within their relationships, the Core Conflictual Relationship

Theme (ccrt) and the consideration of feminist themes are used as frameworks to

enhance clinicians’ understanding of the client’s dynamics.

Luborsky (1997) believed that the ccrt was a valuable approach to setting treatment

goals in short-term hospital settings. It provides a way of both clinicians and clients

increasing their understanding of the client’s relationship difficulties and ways of

overcoming them. The ccrt method is based on the principle that redundancy across

relationship narratives is a good basis for assessing the central relationship pattern.

A relationship pattern consists of:

• the person’s wish in relationships

Clinical Supervision Handbook

• what they experience as the reaction of others (RO) to them

• how they respond to these reactions (the reaction of self (RS).

People generally approach relationships with a wish for something particular from

the other person (e.g., the wish to be loved, validated or generally cared for). They

experience others responding to them in particular ways (e.g., loving, abusive, silencing)

and they react in kind (e.g., withdraw, push the other person away in anger). Through

describing different relationships, the clinician and client can see patterns emerge.

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The pattern is the ccrt (e.g., the client yearns to be loved and noticed but finds that

most people in her life are abusive in different ways. She reacts by withdrawing and

thus experiences loneliness and isolation).

Using the ccrt as an organizing framework, the clinician preparing to present his or her

client would come to the clinical supervision session with the following information:

• client’s initials

• number of sessions (when the client being presented was part of an outpatient

program) or date of admission for inpatients

• identifying data

• age

• history relevant to concerns client is expressing

• relationship experiences/status

• issues related to diversity

• client belief system

Ongoing Clinical Supervision

Provisional ccrt

Wish 1: to be heard and validated for who she is, to have a sense of self, to be able to

establish more effective boundaries

RO (response of others) 1: ignore her, tell her what to do, beat, humiliate or

abandon her

RS (response of self to others’ reaction) 1: feels angry, withdraws, feels like she

cannot make her own decisions and relies on others to do so, feels depressed, pushes

people away, feels silenced

Wish 2: to be taken care of (if I were wealthy, I could live the kind of life I want)

Associated feminist themes: violence, patriarchy, powerful feminine figures (goddess,

grandmother), emphasis on appearance as a measure of worth

RO 2: “You are stupid.” “You do not deserve to live.” “You cannot do what you want

to do (travel, dance).”

RS 2: not take advantage of opportunities, withdraw, “I am too tired to make changes,”

“I am stupid” pushes people away by being difficult to be with or saying she does not

want to commit

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Clinical Supervision Handbook

In addition to the above, clinicians in this program consider information related to

traumatic re-enactments. With this comes the understanding that a common feature

in these clients’ relationships are the roles of perpetrator, victim and rescuer and

how the client can assume these roles interchangeably with others in their lives based

on their childhood experiences. This includes their relationships with clinicians.

After presenting this information to the clinical supervisor and the group, the team

and the clinician working with the client have a better understanding of the underlying

dynamics and can use this to help the client look at alternatives and make sense

of how this pattern continues to be problematic.

Adapted from Luborsky, L. (1997). In T. D. Eells (Ed.), Handbook of Psychotherapy Case Formulation: The Core

Conflictual Relationship Theme. New York, NY: The Guilford Press.

SPONTANEOUS CLINICAL SUPERVISION:

CLINICAL SUPERVISOR AS LIGHTHOUSE

Using the lighthouse as a metaphor for the clinical supervisor presents the image

of a steady beacon for temporarily lost and stranded ships in the fog. The clinical

supervisor can provide direction, guidance and support for safe passage when it is

most needed. The lighthouse connotes a symbol of leadership, assurance, safety

and hope.

In the busy life of a program, it’s important to consider how adhering to a too-rigid

definition of clinical supervision may be a barrier to staff receiving important support

in their work. Requests for clinical supervision can come in many forms. Important

supervision issues, especially in an inpatient setting, often arise spontaneously and,

although it may be unrealistic to expect that the supervisor can provide a totally

comprehensive supervision in a short time (within 10 to 20 minutes), unscheduled

conversations about client care can be consistent with a traditional definition of

clinical supervision. These conversations may also be a starting point for more formal

supervision. Supervisors should be encouraged to consider multiple, brief clinical

conversations that include Socratic questions, affirmation of the supervisee’s skills

and capacities, and promoting client-centred care within a program—as very real

examples of clinical supervision. In other words, the sum of multiple effective contacts

can equal or exceed one scheduled formal session.

If supervision is limited to scheduled conversations, many opportunities for responding

to staff needs for consultation will be lost. Staff needs for support, education and

guidance cannot be totally addressed without this more open access to the clinical

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Ongoing Clinical Supervision

supervisor. Access to the supervisor can be a good way for staff members to flag

issues as they arise and to sort out which ones need to be addressed in the moment

and which ones warrant a more full exploration in scheduled supervision.

In the realm of established and formal clinical supervision, one could argue whether

“clinical supervision on the fly” or “spontaneous clinical supervision” has validity.

Given a culturally diverse staff makeup, along with varying degrees of competency

levels, some staff members may seek spontaneous clinical supervision while others

prefer scheduled supervision. Historically, many nursing staff have come to associate

scheduled supervision with disciplinary action. In such a context, spontaneous

supervision provides a mechanism for clinicians to introduce supervision issues

ahead of time. This may be less of a concern for newer nursing graduates with more

experience at receiving formal supervision than for nurses who may have begun

practising at a time when supervision was associated with discipline. Currently,

nurses receive mentorship during their training and expect it from designated senior

colleagues or their direct supervisor.

Another way of viewing spontaneous clinical supervision is as a vital component

of the life of an inpatient unit in which traditional, scheduled supervision may not

be realistic. Some of the benefits of spontaneous supervision can include reduction

of feelings of isolation on the part of staff and alleviation of feelings of anxiety that

may arise during the work day. One observable factor when assessing how staff

members learn is the use of self-reflection, which might be more familiar for the

allied health professionals. This may be new to some nurses, who might view it

as a luxury they do not have time for. Nurses working on inpatient units are often

expected to work at a fast pace, and at times may feel that stopping for reflection

means that they are putting a greater workload on others or are short-changing the

immediate physical needs of their clients.

Critical support in the areas of education and administration is provided when it

is needed. When guided, staff are able to use independent critical thinking through

process and analysis. The clinical supervisor lets staff problem-solve, which promotes

confidence in their ability to function and provide effective service in the moment

and may help to reduce any possible fears of “admitting a mistake.” Professional

growth is observable through attitude change and a positive perspective toward

learning while doing. As one nurse remarked: “there is a sense of renewed hope, which

fosters a sense of belief in myself.” There is no greater motivator than someone

acknowledging your worth as a clinician, as a colleague and as a person. Open recognition

of excellent performance can bring a much-needed smile to even the most

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Clinical Supervision Handbook

isolated staff member. On the floor it can be seen that clinicians shine with a simple

gesture of thanks, “great work on capturing near-misses,” “what a tremendous work

on that eIPCC” or “great job on assisting that client with transition.”

In addition to the support and guidance provided to staff, the supervisor responding

to these spontaneous requests is modelling clinical skills and techniques important

to the development of therapeutic relationships with clients, such as flexibility, availability

and support. Being flexible and available to staff demonstrates an approach

that clinicians can translate into their relationships with clients. The challenge for

the supervisor is knowing when to back off or redirect staff to scheduled sessions.

If staff are only using these spontaneous opportunities and not engaging in more

formal supervision, then the supervisor may want to explore with the staff the possibility

of setting time aside in advance to discuss clinical practice issues.

Spontaneous clinical supervision is not a brief “quick-fix, give-me-the-answer-now”

interaction. It involves critical educational, emotional and clinical support, which

can open the door for follow-up sessions, in which fuller discussions of clinical

scenarios and dilemmas contribute to the growth of the staff member. Spontaneous

supervision does not replace a more traditional model of supervision but offers a

starting point by engaging staff, is flexible and responsive to the needs of staff working

in a busy program, and can also provide an adjunct to traditional supervision.

CASE EXAMPLE: SPONTANEOUS SUPERVISION

A clinical supervisor on a long-term care inpatient unit was

approached by the charge nurse, who wanted to take time from

her busy day to visit a patient who had been transferred to a general

hospital for medical investigation. She understood that it

would mean turning the charge nurse responsibilities over to

another nurse for that time, but felt that it was important to

respond to the perceived needs of the individual patient. She did

not have a regular clinical supervision time scheduled for that

morning but showed up at the clinical supervisor’s door to

discuss her plan and its implications. The clinical supervisor

provided support and assisted her in developing and following

through on the plan.

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Ongoing Clinical Supervision

The nurse did go to visit the patient and when she returned,

again, flagged down the clinical supervisor because she felt the

need to discuss the case. She reported that her clinical intuition

(although she did not use that term) that a visit by her was needed

was accurate. Because she knew the condition of this patient

so well, she was able to help the staff arrive at the diagnosis of

pneumonia and to provide emotional support for a very ill

patient. This led to a discussion of a recent personal loss for this

nurse and her fears for the future of her patient. This second conversation

only took a matter of 10 to 15 minutes (the nurse needed

to get back to provide noon medications) but in it the clinical

supervisor was able to affirm and support a dedicated staff member

for her clinical assessment and care.

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SPECIAL ISSUES

Interdisciplinary Clinical Supervision

In many therapeutic settings, clinical supervision works with groups that include

staff from many different disciplines. At camh, a nurse educator (NE) and an advanced

practice clinician (apc) regularly provide interdisciplinary clinical supervision in a

longer-term unit within the Schizophrenia Program for an inter-professional staff

made up of registered nurses (RNs), registered practical nurse (rpns), social workers,

occupational therapists and recreational therapists. In this section on special issues,

we will start with their experiences.

We would like to begin with two apparently contradictory thoughts. The first is a

quote that was attributed to H.G. Wells. He called professions the “enemy of the

people.” While one wouldn’t necessarily give much thought to the philosophies of

H.G. Wells, the apc heard it in the context of a conference on recovery, in which

professions were being presented as a way in which professionals distance themselves

from their clients and get into unnecessary conflicts with their colleagues. The second

comes from something heard by the apc from a wise supervisor whose professional

training was in social work. She said that every time she felt certain that she understood

nursing she would find that something that the nurses were pointing out as

a big problem was something that she would not have noticed at all. The apc knows

what she means; when providing clinical supervision with the NE, she will ask a

question about nursing clinical practice and it will take her several minutes to understand

what the NE is referring to and why, but the nurses get the importance of it

immediately and the apc eventually does.

So which approach is right? Is it that the divisions between the professions create

unnecessary gulfs between us, making it impossible to really see and care for our

clients, or is it that we need to become more aware of our differences and more

appreciative of one another’s strengths? The NE and the apc have found that it

is both.

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Clinical Supervision Handbook

In a busy inpatient unit, clinical supervision goes on all the time. The rhythm of the

day cannot be determined in advance. Beginning first thing in the morning, either

the NE or the apc can be stopped by staff with questions about client care and clinical

practice. At first they would just try to answer quickly, and that still happens at

times, but these ongoing questions provide opportunities for discussing clinical care.

It becomes clear very quickly that the NE and apc will each have slightly different

takes on what needs to happen. That might be a problem except for the respect that

each of them feels for the other—both for the unique clinical perspective that the

other brings to each issue and the trust they have in each other’s caring for clients

and staff. And they cannot stress enough that they also bring shared values for

reflective, client-centred care.

There have been times when a nurse wonders aloud to the NE about the apc’s

understanding of their workload. The message that she gives is that the apc can

appreciate and respect their contribution even if she is not a nurse. This confidence

from the NE in the abilities of a social worker to lead nurses sends a reassuring

message that they have the same goals and values in their work.

So what are the important qualities that make interdisciplinary clinical supervision

work, and even work so well as to bring qualities that are greater than the sum of

one nurse and one social worker? As already discussed, awareness and appreciation

of each other’s professional knowledge base and the trust that each brings the best

of these to her work are important. Implied in that is respect. When either one of

them speak, the other listens and they make this clear to staff. In this way they model

professional respect, including respectful communication, to their staff.

STRENGTHS OF THE CLINICAL STAFF

In planning clinical supervision, both the NE and apc spend time reviewing the

strengths of individual staff members, as well as the strengths inherent in professions

they represent. While each profession makes unique contributions to the clients,

there are large areas of overlap, especially in terms of values and goals for clients.

On this particular client care unit, the social workers are the champions of reflective

practice and the big picture of client care; the occupational therapists understand

what clients need to be able to function well in the community; the recreation therapists

are masters at getting clients active after years of inactivity; and the nurses shine

in areas that can seem like a bit of a mystery to the others—what used to be called

patient management, and is now thought of as core nursing practice. As a social

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worker, the apc often listens in admiration to the attention nurses give to the physical

side of client care. As a nurse, the NE expresses appreciation for the initiative and

willingness of the rest of the staff to address all aspects of a client’s life.

STAFF CULTURAL DIVERSITY AND

ITS IMPACT ON CLINICAL SUPERVISION

After joining the team, the apc immediately saw the richness of culture on the unit.

The majority of the nursing staff either comes directly from or is descended from

Africa, the Caribbean or South Asia. The apc with the assistance of the NE, have

sought to distinguish and identify the cultural differences and norms within the team.

This has helped in valuing the wisdom in culturally specific traditions, practices,

beliefs and expectations. For example, the apc realized after establishing a working

relationship with the nursing staff that some of the nurses come from a cultural

background where a one-to-one meeting with a supervisor is culturally acceptable;

by contrast, others prefer and seek the benefit of a “group meeting/supervision” to

find the guiding wisdom of the “elder.”

CONTEXT OF INTERDISCIPLINARY SUPERVISION

The nurse educator was already providing supervision and leadership on this particular

unit when the apc arrived. They immediately began individual training in the

new electronic plan of client care, the eIPCC. Some of the nurses expressed apprehension

about this training. They felt that their typing and computer skills were

lacking and that the new apc would not respect them. Instead, the apc wanted to

talk about the electronic plan of care as a tool for expressing caring and concern

for clients, beginning with common ground, not technical limitations. The apc was

accustomed to using supervision time to support reflective practice and incorporated

it into the training. She found that some nurses were familiar with this approach

but that there were others for whom the questions the apc would ask opened a new

door to nursing care.

For example, “Client lacks insight into their illness” was a common issue presented

in the plan of care. It might be thought that exploring the meaning of this issue with

the client was providing clinical supervision from a social work perspective. This

introspective approach to clinical supervision has been championed by social workers.

By including it in the training it opened the door to reflection, to looking at the care

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for the client, and the goals for his or her future, with a wider and deeper lens than

simply making the goal “Client will gain insight into his or her illness.” Why would

that be our goal? What would the client gain from it? Would the client gain anything

from it? Sometimes using oneself as the example will bring insight: Why would it be

important for me to gain insight into my asthma? How would that help my health or

advance me as a human being?

This led to deeper conversations about the needs of individual clients. It seemed

especially important for the nursing staff, some of whom seemed to believe that they

did not have the right to be that involved in their client’s inner life. The importance

of the nurse educator’s support for this approach by the apc cannot be overstated.

Her vote of confidence for this interdisciplinary approach gave the nurses permission

to develop their clinical skills.

An important part of what makes this partnership work so well is the support of both

the manager and the physicians in the program. Everyone in leadership positions on

this particular unit is “on the same page” when it comes to supporting client-centred

care, clear communication and ethical clinical practice. In daily interactions and

clinical directions large and small, the NE and apc feel confident that their work will

be supported.

INTERDISCIPLINARY SUPERVISION IN PRACTICE

The nurse educator and the advanced practice clinician are often in the position of

working together on staff leadership. Here is a typical example of a situation in which

the two professions are greater than the sum of their parts. In dealing with a conflict

between two nursing staff members, both the NE and the apc each gravitated toward

different but equally important questions regarding clinical practice. The apc asked

each person to reflect on contributions she might be able to make to improve the

situation. The NE focused on clinical responsibility, asking the RN charge nurse / team

leader how she communicated client assignments. Each asked a different version of

the same question but each elicited different and helpful answers, and together they

gave a full picture of how each person approached their professional practice.

Many staff members on the unit have worked in positions in which professions have

been separate and sometimes competitive. Bringing clinical supervisors from two

different professions together to provide clinical supervision to staff from several

professions means providing an opportunity for staff to appreciate the strengths and

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gifts of their colleagues, to learn from one another and improve co-operation in

providing service to their clients.

Nursing and Clinical Supervision

Providing clinical supervision with nurses offers challenges that are unique, particularly

when their work is on inpatient units. As noted earlier, nurses’ experience with

clinical supervision and the meaning attached to it can be different from how social

workers and psychologists see it. For nurses, clinical supervision is often associated

with management rather than clinical practice. For example, nursing supervisors

focus more on operational issues and provide support to staff nurses in the absence

of managers on evenings, nights and weekends around issues such as staffing and

transferring clients between units and to other hospitals.

REFLECTIVE PRACTICE

Nursing and Clinical Supervision

“Reflective practice” is more familiar terminology than “clinical supervision” for

nurses. As members of their professional college, nurses are required to demonstrate

that they have engaged in reflective practice to maintain licensure. This entails being

attuned to the nurse’s own professional needs and ensuring that they obtain the

necessary continuing education to practice competently. Within the college and

university systems, nurses are often asked to reflect on situations with clients in

terms of how they responded, how they understood what went on in light of their

readings/literature, and what alternatives they would consider based on their synthesis

of this information. Analysis of transference and countertransference (see p. 61)

are not generally part of the reflection. A mental health and addiction rotation is

currently not a requirement in training for all undergraduate nursing programs. For

example, one university in Toronto places nursing students at camh in the context

of a “community” experience instead of the more traditional psychiatry placement.

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EXPLORING NURSE’S PERCEPTIONS OF CLINICAL

SUPERVISION

Cleary and Freeman (2005) explored nurses’ perceptions of clinical supervision relative

to other professional support opportunities in acute inpatient mental health settings.

They found that nurses valued having a supportive forum to air their concerns in a

non-judgmental, collegial way, and to discuss practice issues with peers, such as issues

around boundaries with clients. They also viewed dialogue and sharing with their

peers as an opportunity to “reflect on and develop clinical skills” (p. 494). Although

many nurses were aware of the advantages of clinical supervision and supported it in

principle, many preferred informal, ad-hoc approaches with their peers. Most found

it difficult to find the time for clinical supervision, particularly individual clinical

supervision, on a busy, acute care unit and questioned its feasibility. Instead, “informal

support with one’s peers was seen to be more responsive to the clinical realities

of everyday work as generally colleagues were available and accessible” (p. 495).

The clinical supervisor can use this knowledge to help nurses look at the similarities

and differences between what they obtain through these informal means of support

and peer supervision, and what formal clinical supervision can provide. Nurses on

one inpatient unit at camh have identified that although peer support is valuable, it

does not always help them to process their feelings. Hearing others share that they

have had similar feelings and experiences can be validating, but it does not assist

them in seeing connections to their previous personal experiences, wishes or social

location. Sometimes nurses identify with one another’s feelings of powerlessness in

working with a client, making it difficult to gain the objectivity to move beyond

these feelings. The risk of relying on peer support alone is that the status quo may

be maintained and alternative approaches or ways of understanding a situation may

not be considered.

PRACTICAL ISSUES

More than other disciplines, nurses on inpatient units rotate shifts. This makes

consistent attendance at group clinical supervision sessions more difficult. To

accommodate their schedules, the group clinical supervision happens in open rather

than closed sessions. This can have an impact on group cohesion when membership

changes from session to session. Given the high turnover of clients on inpatient

areas, the focus of the clinical supervision tends to change from session to session

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ather than staff being able to talk about particular clients over an extended period

of time. One way of attending to this, particularly given the “revolving door” nature

of hospital admissions, is to provide time to discuss clients who are re-admitted as

an opportunity to learn from their previous stays. This underlines the importance of

the clinical supervisor being flexible and available to address the issues that can arise

on an inpatient unit spontaneously on a day-to-day basis. This is further discussed

in Spontaneous Clinical Supervision: Clinical Supervisor as Lighthouse, p. 66.

Nurses on inpatient units have 24-hour responsibility for their clients and no separate

office space. On one unit they described feeling as though they are in a fish bowl,

constantly being observed and accessible to clients in a way that other professionals

are not. This makes boundary setting with clients more challenging. Nurses may feel

powerless because they feel they have less control over their environment.

Nurses usually see clients when the clients are in crisis. They are less likely than other

members of the team to see clients at other stages in their lives such as when they are

functioning in the community. Nurses attend to a broad range of clients’ needs that

include physical as well as emotional needs, and are involved in tasks such as providing

medication, restraining clients, caring for wounds and establishing a therapeutic

relationship. This places nurses within the client’s personal space in ways that are

quite different from other disciplines. This is an important difference for the clinical

supervisor to consider.

PREPARATION

Nursing and Clinical Supervision

Since nursing staff may not be familiar with the process of clinical supervision, clinical

supervisors should provide education up front about what clinical supervision is and

is not in order to develop a “safe” environment where nurses are willing to disclose

their practice challenges. The preparation includes:

• acknowledging their unique position on the team and how that affects their

client interactions

• differentiating between the procedural activities that are the focus of

administrative supervision

• explaining the differences between therapy and clinical supervision to reinforce

the respect for appropriate boundaries between the clinical supervisor and

the nurse.

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The clinical supervisor explains that the focus is on the professional development

of the nurse in the context of his or her work with the client, rather than on the

development of action plans for the nurse’s personal problems. In other words, the

focus is on the nurse’s process and behaviour with the client. The clinical supervisor

explains that clinical supervision is an opportunity for nurses to turn what they

know and feel into skillful action by paying deliberate attention to their experience,

and critically analyzing feelings and observations. The intended outcome is a new

perspective on a situation that they initially found puzzling or surprising.

A Multi-Method Professional

Development Approach in

Daily Practice

INTEGRATED CARE AND BUILDING CAPACITY IN

THE SCHIZOPHRENIA PROGRAM

In order to support staff to practice new skills and reflect on how it will change clinical

practice, staff members have needed supervision and coaching to increase their

confidence and knowledge base to address concurrent disorders. One of the camh’s

strategic directions focuses on providing integrated care to clients. Best practice literature

suggests that program integration means:

[M]ental health treatments and substance abuse treatments are

brought together by the same clinicians/support workers, or team of

clinicians/support workers, in the same program, to ensure that the

individual receives a consistent explanation of illness/problems and a

coherent prescription for treatment rather than a contradictory set of

messages from different providers. (Health Canada, 2001, p. vii)

Consequently, the clinical staff continues to develop skills to address how addictions

and mental health impact each other when working with clients.

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A Multi-Method Professional Development Approach in Daily Practice

Historically, clients were sent to specialized programs that separated mental health

and addictions. In the Schizophrenia Program, many of the staff participated in

trainings to address concurrent disorders. The staff has been working toward providing

integrated care. While many staff members are addressing these issues regularly,

some also express the concern that maybe “I could be doing more” as a clinician.

W.R. Miller et al. (2006) note that “to learn any new behavioural skill, people need

not only informational training but also:

• clear and accurate feedback regarding their performance

• guidance from a supervisor / coach who has greater expertise and proficiency in

the skill.

Without performance feedback, significant change in practitioner behaviour does

not occur.” (W.R. Miller et al., 2006, p. 35) While trainings provide clinicians with a

foundation around theory, there is a lack of confidence expressed by staff members

in their ability to provide integrated treatment. They say that they need ongoing

practice to develop skills in developing concurrent disorders treatment.

Coaching/Partnering Style of Supervision

A Motivational Interviewing Approach

An approach to clinical supervision has been used to help staff members develop

their clinical skills around concurrent disorders. This approach involves coaching

and gives clinicians an opportunity to work with the clients who are actively using

substances. The clinical supervisor uses a motivational interviewing approach that

promotes a coaching rather than instructional style. Clinical supervisors model and

teach motivational interviewing approaches in the way that they work with the clinician,

as well as the client. The coach communicates to the clinician that ambivalence

is expected when clients are considering changing their substance use patterns, and

that clients choose whether or not to make a change. Typically clinicians seek out

this support from the supervisor when clients are in an early stage of treatment

and may be starting to consider making a change in their substance use (e.g., the

engagement or persuasion stage of treatment). These stages are defined by Mueser

et al., 2003, pp. 123-124).

During this process, the role of the clinical supervisor evolves from one of cofacilitator

and role model to observer as the clinician develops the skills and confidence

needed to provide integrated care. Initially, the clinical supervisor may be more

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engaged with the client, but over time steps back. The supervisor role is explained to

the client so that she or he knows that the primary relationship is with the clinician.

The clinical supervisor and clinician usually contract that every four sessions they

will evaluate and decide whether to re-contract to continue the process. The client

is also consulted about the length of involvement to see if this matches his or her

goal for treatment. The clinical supervisor asks for written evaluations from the

clinician to assess the usefulness of this role. The clients have also been asked to fill

out evaluations on their experiences. This approach has been used primarily for

individual sessions.

Group supervision

When the clinical supervisor is involved in coaching/supervising staff in co-facilitating

a group on concurrent disorders, the contract is usually for a longer time period.

The focus in this setting is to help staff develop skills needed to work with clients

presenting with concurrent disorders issues. Some clinicians may also need help with

developing group facilitation skills. For example, a clinical supervisor and clinicians

work together to develop a handbook that would guide the staff in facilitating sessions.

The long-term goal for the clinical supervisor is to step back, observe and provide

feedback until the clinicians decide they are ready to continue facilitating the group

on their own. The clinical supervisor often becomes more of a clinical consultant as

needed, rather than a supervisor or coach.

Community of practice

Beitler (2005) discusses the idea of a community of practice as a group of like-minded

clinicians who are interested in exploring and developing skills in a specific practice

area. He notes:

The primary focus is the sharing of experiences and new ideas that

members can use in practice. Key themes include a domain of common

issues, developing a sense of community that includes trust and

a social bond, and the element of practice. The majority of the members

must be seasoned practitioners who are bringing their issues,

ideas, advice and applying this knowledge to their practice, and then

reporting back their experiences (pages 1, 7–8).

(Beiter, M.A. (2005). “Strategic Organizational Learning.” Greensboro,

NC: Practioner Press International. (pp. 70-77)).

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A Multi-Method Professional Development Approach in Daily Practice

Beitler indicates that the co-ordinators do not have to be the leading experts in the

field, but do need to be passionate about the knowledge domain and be well respected.

One such project has been a pilot of a Motivational Interviewing Community of

Practice. These sessions provide opportunities for people with more advanced training

in motivational interviewing to practice skills through participation in role plays,

watching videos and discussing challenges in their practice. This process of learning

gives clinicians an opportunity to review best practice literature, learn from each

other and practice skills. Peers take responsibility for the sessions. The early sessions

have been organized and co-facilitated by a group of clinicians who are experienced

in the area of motivational interviewing and have provided training in this area. This

project is in its beginning phase. Initial evaluations have been positive. Clinicians

are invited to participate in planning and continuing the developing of this learning

initiative. In addition, a practice is being developed with staff members who are less

experienced in motivational interviewing in the Schizophrenia Program. The staff

are working to apply the recovery model and want to practice skills of motivational

interviewing. Staff may have less experience with motivational interviewing, but would

like to develop skills; share knowledge and challenges; and develop confidence in their

practice. In the near future, as this project continues, there may be access to a listserv

to help people share articles, discuss clinical challenges and network around motivational

interviewing issues.

Concurrent disorders journal club

These journal clubs started out as a way to share best practices on integrated care.

This learning is not clinical supervision but a way of sharing information based

on readings from the book Treating Concurrent Disorder: A Guide for Counsellors

(Skinner, 2005). This six-session group is held monthly and is facilitated by one or

two staff members who specialize in concurrent disorders. Each month one of the

authors comes to discuss his or her chapter. The meeting focuses on comments,

thoughts, and questions related to the chapter (e.g., motivational interviewing, family

issues, youth and setting up group programming). The clinicians are asked to evaluate

this learning experience at the end of the cycle. Approximately 10 people are involved

in each journal club.

An advanced journal club has evolved in response to people’s participation and

interest in further learning. In this group, guest speakers focus on a topic related to

concurrent disorders best practices guidelines. Clinicians share clinical scenarios

and request feedback. This format is continuing to evolve as the clinicians suggest

learning ideas. As staff develop their skills and confidence in working with clients

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that present with concurrent disorders issues, they are providing leadership in facilitating

and organizing the journal clubs. As stated by Miller, et al. (2006), “a persistent

novice golfer on a driving range can gradually learn how to drive a ball farther, but

learning can be substantially accelerated by a little coaching from an experienced

professional” (pp. 35-36).

Ethical Considerations in

Clinical Supervision

Because the clinical practice environment is becoming more complex, clinicians are

bringing clinical scenarios to supervision sessions that defy neat and tidy resolutions,

thus challenging clinical supervisors to tread ethical paths they may have never

encountered in their own front-line careers. For this reason, a new emphasis has been

placed on the importance of ethics training for all clinical supervisors, no matter how

much clinical experience they have to inform their work with clinicians.

Frederic Reamer, a professor of social work in the United States, has done extensive

work on ethical considerations in clinical practice and supervision (Reamer, 1994,

1999, 2001, 2003). He emphasizes that it is crucial for clinical supervisors to have

the skills and background necessary to develop in their clinicians a way of thinking

ethically, since it is not possible to have hard and fast rules about many of the dilemmas

encountered in clinical practice. This way of thinking involves ethical decision-making,

which takes into account conflicting values and duties, identifies individuals and

groups likely to be affected by a certain decision, and tentatively identifies all possible

courses of action with possible risks and benefits. In addition, Dr. Reamer’s approach

examines reasons for and against each possible course of action. He recommends

that ethical theories, principles and guidelines; codes of ethics; legal principles;

discipline-specific practice theory and principles; personal values; and agency policies

and regulations all be used to inform the examination.

In a 14-week graduate social work course at Rhode Island College, Dr. Reamer

covers a wide range of “key risk areas,” which he maintains are taken into account

by good quality clinical supervision. The areas include:

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• client rights

• confidentiality and privacy

• informed consent

• service delivery

• boundary issues and conflicts of interest

• documentation

• defamation of character

• client records

• supervision

• staff development and training

• consultation

• client referral

• fraud

• termination of services and client abandonment

• practitioner impairment

• evaluation and research.

STANDARD OF CARE

Ethical Considerations in Clinical Supervision

Dr. Reamer points to the principle of “standard of care,” which he defines as “what

an ordinary, reasonable, and prudent professional, with the same or similar training,

would have done under the same or similar circumstances.” He considers this the

most important sentence in clinical supervision. It can guide discussion of complex

clinical dilemmas. Dr. Reamer cites two types of standards of care.

• A “substantive” standard of care is one that is widely accepted across clinical

practice settings, for instance, the norm that dating clients is indefensible on

ethical grounds.

• “Procedural” standards of care cover processes that are invoked with difficult,

ethically complex scenarios—cases in which experienced clinicians and practice

leaders commonly disagree about what constitutes the best course of action.

Activities that encompass procedural standards of care include consulting with

colleagues and supervisors; reviewing relevant ethical standards; reviewing relevant

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laws, policies and regulations; reviewing relevant literature; obtaining legal consultation

when necessary; consulting an ethics committee, if available; and documenting

decision-making steps.

ETHICAL CONSIDERATIONS: AN EXAMPLE

It is beyond the scope of this guide to cover the depth and breadth of what ethical

training clinical supervisors require. However, it may be helpful to consider a common

clinical issue in which ethical considerations figure prominently. Client discharge

or termination provides a good example. In many instances, clinicians may struggle

with decisions to discharge a client before he or she has completed a treatment

program. This struggle may involve weighing the circumstances that precipitated the

potential discharge against an appreciation of the client’s significant ongoing needs.

If the decision to discharge is carried out, Dr. Reamer recommends the following

guidelines to protect clients and minimize risk:

• Provide clients with names, addresses and telephone numbers of at least three

appropriate referrals.

• Follow up with a client who has been terminated. If the client does not go to

the referral, write a letter to him or her about relevant risks.

• Provide as much advance warning of the termination as possible.

• When clients announce their decision to terminate prematurely, explain the

risks involved and suggestions for alternative care. Include this information

in a follow-up letter.

• Carefully document in the case record all decisions and actions related to

termination.

• In cases involving discharge from residential facilities, prepare a comprehensive

discharge plan and, with client consent, notify significant others.

• Provide clients with clear instructions to follow in the event of an emergency.

Ask clients to sign a copy acknowledging that they have received the instructions

and that the instructions were explained to them.

• Consult with colleagues and supervisors about termination strategy and decisions.

• Consult relevant code of ethics standards.

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Evaluating Clinical Supervision

Although clinical supervision is regarded as an important factor in enhancing client

outcome in mental health and other human service settings, there is limited research

support for the effectiveness of clinical supervision (Strong et al., 2003). In particular,

there has been a call for research in the following areas:

• evaluating supervisory training

Evaluating Clinical Supervision

• examining diversity issues in clinical supervisor-clinician relationships and in

various service settings

• exploring the impact of clinical supervision on client outcomes (Bruce & Austin,

2000).

Some recent exploratory research addresses key areas related to evaluating the clinical

supervision context and supervisor skills. Areas that have been addressed include:

• core competencies in supervision (Falender et. al., 2004)

• diversity / cultural competence in supervisors (Armour et al., 2004)

• benefits and barriers to effective clinical supervision (Strong et al., 2003)

• trainee preferences in clinical supervisor feedback (both positive and negative)

(Heckman-Stone, 2003).

This section will summarize these findings and will provide a number of concrete

suggestions for evaluation approaches and tools that can be used in clinical supervision.

The section will conclude with a brief discussion of the importance of documenting

supervision in clinical settings—an area that has been identified as being of key legal

and ethical importance (Falvey & Cohen, 2003). Note that performance evaluation

of clinicians is not addressed in this section, as it falls outside of the purview of

clinical supervision camh, and is already carried out annually using approved

protocols and tools.

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Clinical Supervision Handbook

Core Competencies in

Clinical Supervision

Falender and colleagues (2004) recently published a consensus statement on core

competencies in psychology supervision. This was done in response to recommendations

arising from an international working conference held in 2002. The primary

aim was to identify areas of consensus and difference in a variety of research and

practice domains, including clinical supervision. (For more information about conference

topics and membership, see Falendar et al., p. 773.) Falender and colleagues

note that identifying competencies helps move professions from normative (or subjective)

assessments to criterion-based (or objective) assessments. This approach has

the advantage of introducing greater rigour to the clinical supervision process as well

as to the performance and techniques of individual supervisors. A brief overview of

these core competencies sets the stage for a discussion of what we might evaluate in

clinical supervision, and how this can be best carried out.

Although the competencies outlined below were developed in reference to the

discipline of psychology, they are broadly applicable and relevant to other clinically

focused disciplines such as social work, nursing, medicine, psychiatry, occupational

and recreation therapy. Clinical supervisor competencies have been divided into six

general categories, with a number of micro-skills within each area. The broad competencies

of knowledge, skills, values, social context / overarching issues, training

and assessment are summarized in Table 1. The final area, assessment, is particularly

relevant to evaluation of clinical supervision. Note that the wording of the discrete

micro skills has been somewhat adapted to better reflect clinical practice at camh.

TABLE 1: SUPERVISION COMPETENCIES AND MICRO-SKILLS

COMPETENCY AREA MICRO SKILLS

1. KnowledgeKnowledge of area being supervised

Knowledge of relevant models, theories, interventions and

research

Knowledge about clinicians’

• Learning and professional development

Knowledge of ethical and legal issues relating to supervision

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COMPETENCY AREA MICRO SKILLS

Core Competencies in Clinical Supervision

Knowledge of clinical outcome and process evaluation

Knowledge and awareness of diversity, marginalization and

oppression issues and diversity competence

2. Skills • Supervision methods

• Relationship skills (building a supervisory alliance)

• Sensitivity to multiple roles with supervisee and able to balance

multiple roles

• Ability to provide constructive and effective feedback

• Ability to promote supervisee self-assessment and growth

• Ability to conduct own self-assessment process

• Ability to assess supervisee’s learning needs and developmental

level

• Ability to encourage and use evaluative feedback from

supervisees

• Teaching skills

• Ability to set appropriate boundaries and seek consultation/

supervision (assess own competence)

• Flexibility

• Integrating and presenting evidence-based practice and

best practice principles

• Documentation procedures

• Ability to impart evidence-based practice knowledge within

the supervisory session

3. Values • Supervisor is accountable for supervision provided—to

supervisee and to client

• Respectful

• Responsible for diversity awareness and competence

• Balance between support and constructive feedback/

challenging

• Empowering

• Commitment to continuous learning and professional growth

• Balance between clinical and training needs

• Valuing ethical principles

• Knowing and using supervision research and best practices

• Committed to knowing own limitations

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COMPETENCY AREA MICRO SKILLS

4. Social context / • Diversity

overarching • Ethical and legal issues

issues • Developmental process

Knowledge of organization and expectations re. clinical

supervision

• Awareness of socio-political context within which supervision

is conducted

• Creation of climate in which authentic, honest feedback is

the norm (both supportive and challenging feedback)

5. Training in • Continuing education in supervision knowledge and skills

supervision • Receives supervision of supervision, including observation

competencies (videotape/audiotape/in vivo observation with critical

feedback)

6. Assessment of • Successful completion of supervision course / workshop

supervision • Documented evidence of supervision of supervision, noting

competencies readiness to supervise independently

• Evidence of direct observation

• Documented evidence of supervisory experience reflecting

diversity competence

• Documented supervisee feedback

• Self-assessment and awareness of need for

consultation / supervision when necessary

• Assessment of supervision outcomes

• Impact of client outcomes

Adapted from Falender et al., 2004, p778

Clinical Supervision Handbook

Based on the micro-skills outlined in competency number six, assessment of

supervisor competencies, evaluation of clinical supervision should ideally incorporate

the following elements:

• Certificate of completion of some form of continuing professional education

(e.g., course, workshop) in clinical supervision

• Documentation that the supervisor has had supervision that focuses on his or her

role as supervisor, and recommendations (with follow-up and development plan)

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Core Competencies in Clinical Supervision

Clinical supervisor self-assessment (reflective practice) (e.g., through attendance

in a supervisors’ supervision group, or through openness to learning from and

implementing evaluation feedback by supervisees)

• Evidence of diversity competence (e.g., completion of camh diversity training,

other measures of diversity / cultural competence, which can be used with both

supervisor and supervisees)

Clinical supervisor evaluation (completed by clinicians)—both process and

outcome (e.g., using the Supervision Feedback Scale (Heckman-Stone, 2003),

discussed on page XX in this section)

• Link to client outcomes—possibly via the Interdisciplinary Plan of Client Care

(ipcc) if possible.

BENEFITS AND BARRIERS TO

EFFECTIVE CLINICAL SUPERVISION

In order to better understand the clinical supervision context, its strengths and areas

for improvement, Strong and colleagues used focus groups and brief interviews to

explore clinical supervision practice among allied health professionals in a large

mental health service. The focus group questions, which closely mirrored the questions

used in the brief interviews, can provide a useful, semi-structured guide for

carrying out periodic process evaluations of clinical supervision groups. The questions

asked included:

• What do you see as the benefits of supervision?

• What would you regard as ideal supervision in your profession?

• What do you see as the best aspects of current supervision practices in your

employing organization?

• In what ways is current supervision less than ideal?

• What are the main barriers to good supervision in mental health service?

• What issues have been raised by your experiences with cross-professional

supervision?

• What are the three most important things that need to be done to improve

supervision practice? (Strong, et al., 2003, p. 195)

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If a culture of authenticity and honesty is fostered in clinical supervision groups,

periodically reflecting on the process of clinical supervision can lead to valuable

insights and enhanced effectiveness of the supervisors. The research found that clinical

supervision was a key to improving clinical competence and implementation of best

practices, as well as a source of support for staff. The main barriers identified were

the absence of a clear organizational policy on clinical supervision and failure to

allocate sufficient resources to support clinical supervision practice. Articulating a

model of clinical supervision and a training agenda were also seen as primary issues.

It may be interesting and illuminating to compare the experiences and perceptions

of camh clinicians with the findings of Strong and his colleagues (2003).

EVALUATING DIVERSITY COMPETENCE IN CLINICAL

SUPERVISION

The issue of diversity competence has been identified as being of key importance in

clinical supervision, and is reflected in a number of the core micro-skills of clinical

supervisor competencies noted above. As Divac and Heaphy (2005) point out,

“developing cultural competence is now a requirement for achieving appropriate

professional standards in therapy and supervision training” (p.282). Diversity is a

factor not only in working with clients, but in the heterogeneity of supervision groups

and dyads as well. Thus, diversity competence is relevant in clinical supervisors’

feedback around case formulation and intervention, and in power dynamics, experiences

of privilege/oppression/marginalization, and working across difference in the

clinical supervision context. There is a small but growing literature focused on the

development, application and evaluation of diversity / cultural competence in clinical

supervisors (Armour et al., 2004; Constantine et al., 2005; Divac & Heaphy, 2005).

Evaluation tools

Clinical Supervision Handbook

A number of tools have been developed and validated for use by instructors, clinical

supervisors and/or clinicians. These range from brief process evaluations to more

extensive summary evaluations. These tools may help clinical supervisors to assess

their own competence in this area.

Armour et al. used a closed-ended, 13-item, self-administered questionnaire and

anonymously written responses to five reflecting questions in a repeated measures

design. (A copy of the closed-ended questionnaire is included in Armour et al.’s

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Core Competencies in Clinical Supervision

article as an appendix, p. 38.) Both clinical supervisors and clinical supervision

groups could use this tool to periodically assess progress in diversity competence,

and to stimulate discussion about areas for professional and personal growth.

The questionnaire addressed comfort with diversity; awareness of issues of power,

control and interpersonal conflict; and knowledge about oppressed groups. The

added open-ended reflecting questions included:

• highlights in practitioners’ diversity training experiences

• peak enjoyable or disturbing experiences (or both) in diversity training

• an idea or skill supervisors could use with supervisees

• how supervisors’ insights (facilitated by their responses to previous questions)

could contribute to their effectiveness in supervision

• actions that supervisors could take to enhance the cultural competence in their

agency or program. (Armour et al., 2004, p. 34)

The study showed significant gains in diversity awareness in the period between the

end of the training and follow-up. Clinical supervisors also noted areas for further

development in improving supervision practice, including normalizing discomfort,

awareness of retreating from exploring diversity, and permission to address “socially

taboo” topics.

Divac and Heaphy (2005) suggest that ongoing feedback and reflection in supervision

of supervision sessions is an important formative evaluation strategy for diversity

competence. They also suggest that semi-structured interviews with trainee supervisors

should be carried out at the end of the academic year. (The content of the interviews

was not yet developed by the authors at the time of publication of their article.)

Divac and Heaphy describe the content and format of monthly sessions for clinical

supervisors, where the specific focus was on fostering diversity competence. This

approach may be of particular relevance to the professional development of clinical

supervisors due to its richness in process and experiential emphasis. In this model,

trainee supervisors meet one day per month to discuss key issues, skills and abilities

in cross-cultural practice. Divac and Heaphy note that the main focus is on the

process and experience of engaging with subjective assumptions, biases and experience

related to their own and others’ cultures. In addition, trainees use the group format

to reflect on diverse aspects of their identities, which may be privileged in some

contexts and disadvantaged in others. Finally, group sessions are videotaped and

reviewed to encourage continued reflection and exploration of issues.

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Clinical Supervision Handbook

In another study, Constantine, Warren and Miville (2005) present and discuss the use

of the multicultural case conceptualization ability exercise, a tool and coding system

used to determine the extent to which clinicians are able to integrate salient cultural

issues into two different conceptualizations of a client case.

Finally, Pope-Davis and colleagues (2000) describe the development and validation

of the Multicultural Environmental Inventory—an instrument designed to measure

the degree to which graduate counselling programs address multicultural issues in

their curricula, clinical supervision, climate and research. The instrument was condensed

from 53 to 27 items based on the results of factor analyses, and showed promise

in its ability to assess change over time, as well as good validity and reliability. Although

designed for academic settings, it may be useful to test either the instrument as a whole,

or the supervision subscale, as a way to evaluate clinical supervisors’ effectiveness in

addressing and promoting cultural competence in clinical supervision groups.

Cultural and diversity competence is now being addressed in a more rigorous fashion

in clinical supervision settings. This reflects a growing awareness of their importance,

and of the need for ways to assess and identify gaps in knowledge and skills (both in

clinical supervisors and in front-line clinicians).

CLINICAL SUPERVISOR EVALUATION

Providing and accepting clear and concrete feedback, identifying strengths and areas

for improvement, and specific concerns with respect to good clinical care can be

difficult for both clinical supervisor and clinician. Yet “when supervisees reflect on

their supervision, what comes to mind most often is the quality and quantity of

feedback they received” (Bernard & Goodyear, 1998). Therefore, clinical supervisors

need to evaluate the extent to which they are providing constructive and salient

feedback to clinicians.

Heckman-Stone (2003) carried out a pilot study with 40 graduate students from

three training programs (counselling psychology, clinical psychology and masters

degree in counselling). She used a scale of 10 items rated on a seven-point, Likert-type

scale, where 1= strongly disagree, 4 = neutral, and 7 = strongly agree. In addition,

the author included four open-ended items designed to elicit examples of positive

and negative feedback in clinical supervision, and the characteristics of good

and poor use of feedback and evaluation by clinical supervisors. An example of

the instrument, adapted for use with more experienced clinicians—as opposed to

92


students—is presented below. Based on the results of the pilot study, Heckman-

Stone outlines a number of recommendations in providing feedback to clinicians.

These include:

• Begin by describing the process of supervision.

• Set clear, mutually agreed upon performance criteria.

• Reliably observe the supervisee’s work.

• Compare the observations with performance objectives/criteria.

• Have supervisee provide a self-evaluation first.

• Start with positive evaluations.

Core Competencies in Clinical Supervision

• Specify the skill area being addressed in giving the feedback.

• Have supervisees set the agenda for supervision sessions as much as possible.

• Monitor supervisees’ use of feedback and evaluation.

The Clinical Supervision Feedback Scale can be used as either a process or outcome

evaluation for clinical supervisors to assess their skills in providing feedback, and

identify areas for development. Another structured clinical supervision evaluation

instrument, the Group Supervisory Behavior Scale (gsbs, White and Rudolph, 2000)

has also been demonstrated to have good reliability and validity, and may be useful

in evaluating supervisor behaviours in group supervision contexts.

CLINICAL SUPERVISION FEEDBACK SCALE

(1 = STRONGLY AGREE; 4 = NEUTRAL; 7 = STRONGLY AGREE)

1. My supervisor welcomed comments about his or her

style as a supervisor.

1 2 3 4 5 6 7

2. My supervisor’s comments about my work

were understandable.

1 2 3 4 5 6 7

3. I didn’t receive timely information about how

I was doing as a therapist. [reverse scored]

1 2 3 4 5 6 7

4. I have had written feedback from my supervisor

about my clinical work.

1 2 3 4 5 6 7

5. My supervisor balanced his or her feedback

between positive and negative statements.

1 2 3 4 5 6 7

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6. The feedback I received from my supervisor

was based on his or her direct observation of my work

(including video / audiotapes).

1 2 3 4 5 6 7

7. The feedback I received was directly related to

the goals I set in supervision.

1 2 3 4 5 6 7

8. There were inconsistencies between my supervisor’s

feedback to me in session and written feedback.

[reverse scored]

1 2 3 4 5 6 7

9. I am satisfied with my supervisor’s use of feedback

in session.

1 2 3 4 5 6 7

10. I am satisfied with my supervisor’s written feedback. 1 2 3 4 5 6 7

Open-ended items:

11. Please describe a positive experience you have had

with feedback in supervision.

1 2 3 4 5 6 7

12. Please describe a negative experience you have had

with feedback in supervision.

1 2 3 4 5 6 7

13. Please list characteristics of good use of feedback

by your supervisor.

1 2 3 4 5 6 7

14. Please list characteristics of poor use of feedback

by your supervisor.

1 2 3 4 5 6 7

Adapted from Heckman-Stone, 2003, p.28.

Clinical Supervision Handbook

DOCUMENTATION OF SUPERVISION

IN CLINICAL SETTINGS

The importance of documentation in clinical supervision cannot be overstated, and

is an important source of evaluative feedback to clinicians. As Falvey and Cohen state:

Keeping records is standard practice for virtually all human services

and medical disciplines. From a legal as well as an ethical perspective,

if it isn’t documented, it didn’t occur. The question for supervisors,

then, is not whether to document, but how to do so in an efficient

manner. (Falvey et al., 2003, p. 77)

94


The authors note that over-documentation can be as much an issue as under-documentation,

and suggest the use of structured forms to capture case review data and

recommendations. Falvey et al. also strongly recommend that clinicians not be given

sole discretion in selecting cases for review in clinical supervision. They note that

clinicians may not recognize important practice issues in all cases, and that significant

client care problems or issues may not be addressed unless all cases are periodically

reviewed. As the authors state:

Leaving the choice of which cases to review up to the supervisee, while

commonplace, is not an ethically or legally viable supervisory practice.

Evaluation anxiety, concern over clinical errors or boundary violations,

negative reactions to the supervisor, or failure to recognize the

importance of clinical signs and symptoms contribute to a high rate

of supervisee nondisclosure. (Falvey et al., 2003, p. 72)

Falvey and Cohen also highlight the importance of a clinical supervision contract,

records of all clinical supervision sessions (with details on cases discussed and

decisions made); notes on cancelled or missed supervision meetings, and on significant

conflicts in clinical supervision sessions and how they were handled. These documents

can assist in identifying training/professional development needs, and provide

“evidence of competent supervision should a supervisee grievance or client lawsuit

subsequently arise” (Falvey & Cohen, 2003, p.68). They present samples of forms

developed as part of a clinical supervision process evaluation/tracking package, titled

the Focused Risk Management Supervision System (FoRMSS). (The authors provide

sample forms in their article; see pages 73, 74 and 76.) These forms (or FoRMSS) can

be adapted for use in clinical supervision groups as a way of maintaining a record of

case discussions and a process evaluation of clinical supervision issues and outcomes.

Conclusion

Core Competencies in Clinical Supervision

Evaluation of clinical supervision is a complex and challenging task. However, it

is crucial to fostering transparency, accountability and modelling of best practices.

Areas for further research identified in the literature include evaluating/assessing

clinical supervisors’ diversity competence, and demonstrating the impact of clinical

supervision on client care outcomes. The latter may be facilitated by more active use

of the Interdisciplinary Plan of Client Care (ipcc) in clinical supervision sessions,

where ipcc goals and outcomes are routinely discussed as part of the case review

and clinical feedback process. In the absence of clear and unequivocal empirical

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Clinical Supervision Handbook

support for best practice tools in clinical supervision assessment and evaluation,

these preliminary instruments and scales should be regarded as a starting point in

introducing greater rigour and accountability into the clinical supervision context.

FIGURE 2: INTERDISCIPLINARY PLAN OF CLIENT CARE (IPCC) FORM

Available in pdf and Word versions on Insite:

http://insite.camh.net/forms/clinical_forms/10258_interdisciplinary_plan_of_client_care.html

96


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APPENDIX 1

Conceptualization of Clinical

Supervision: A Review of the Literature

SOCIAL WORK

Supervision in social work is essentially conceived of as a method to ensure the

organization’s mandate is achieved by enhancing the supervisee’s* ability to provide

effective service. The supervisor is accountable for the job performance of agency

workers (Kadushin, 1976; Kadushin & Harkness, 2002) with administrative, educational

and supportive activities being used to achieve this goal. Supervision scholars in

social work agree on the importance of a positive relationship between supervisor

and supervisee as the context for learning and performance (Barretta-Herman,

1993; Kadushin & Harkness, 2002; Munson, 2002; Shulman, 1993, 2005) while

emphasizing the parallel process in the working relationship between client-worker

and worker-supervisor.

Three interrelated functions of supervision were proposed by Kadushin (1976)

—administrative, educational and supportive—a conceptualization that has continued

to receive support (Bruce & Austin, 2000; Munson, 2002; Shulman, 1993).

Administrative supervision encompasses selecting and orienting workers/clinicians;

assigning cases; and monitoring, reviewing and evaluating work. It serves as a

socializing agent, advocating, and buffering within the organization. Agencies grant

supervisors authority to direct others’ work and they use both formal power such

as rewards, coercion, position in the organization, and informal power derived from

their expert knowledge and relationships with their supervisees.

*The term supervisee is used in this section to maintain consistnecy with the literature.

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Educational supervision encompasses activities that develop the professional capacity

of supervisees, including teaching knowledge and skills, and developing self-awareness

(Barker, 1995; Munson, 2002) through, for example, teaching, case consultation,

facilitating learning and growth. Kadushin and Harkness (2002) note that in the

general social work supervision literature, the term clinical supervision frequently

refers to a focus on the professional practice of the supervisee. Others associate clinical

supervision with an analytic focus on the dynamics of the client situation and the

worker’s interventions and interactions with clients (Gibelman & Schervish, 1997).

We prefer the definition of clinical supervision in professional psychology, which

includes both enhancing the professional performance of the junior member of the

profession while monitoring the quality of services offered to the client (Bernard

& Goodyear, 2004). Supportive supervision encompasses helping workers handle

job-related stress by providing appropriate praise and encouragement, normalizing

work-related reactions, affirming strengths and sharing responsibility for difficult

decisions (Kadushin & Harkness, 2002). Stress is related to the emotional demands

on social workers faced with traumatic and acute social problems that may be

challenging to articulate within the supervision setting (Barretta-Herman, 1993).

Supportive comments are meaningful when given within the context of a relationship

with a respected and valued supervisor (Kaiser & Barretta-Herman, 1999).

In an analysis of themes in the supervision literature, Bruce and Austin (2000) predict

that supervisors in the future would need to incorporate the following: change

management skills including understanding the multiple governmental, community

and organizational contexts of practice; practice in racially and culturally diverse

organizations and communities; use of client outcomes to monitor service delivery;

and processes that promote effective inter-professional work.

In summary, this review of the literature found a view of supervision for social work

that includes the interrelated elements of administration, education and support.

Each of these factors influences all of the others and, when operating in concert,

produce more effective services for clients. Separating educational or clinical elements

from this holistic definition distorts the fundamental essence of social work supervision.

Similar to principles of effective practice, supervision is an interpersonal and interactional

process between worker and supervisor. The importance of offering and

modelling positive elements in a supportive, performance and outcomes-oriented

relationship is reinforced in the literature.

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Conceptualization of Clinical Supervision: A Review of the Literature

Toward an evidence-base for clinical social work supervision

Does the research on social work supervision provide evidence to support this

conceptual model and related principles and practices? Two recent reviews of the

empirical research on social work supervision, one spanning 1970–1995 (Tsui, 1997)

and one spanning 1994–2004 (Bogo & McKnight, 2005) uncovered a dearth of studies

in this regard. The existing studies used small sample sizes, used exploratory, survey

and cross-sectional designs; and contributed modestly to theory-building or providing

evidence for best practices. The studies reviewed, however, did offer some support

for some elements identified in the conceptual literature. For example, Erera and

Lazar (1994) found supervision consisted of the three major functions: administrative,

educational and supportive. A number of studies investigated the organizational

context of supervision and found that the agency’s mandate and focus shape the nature

of supervision provided (Berger & Mizrahi, 2001; Gibelman & Schervish, 1995,

1997; Gleeson & Philbin, 1996). Organizational climate affects supervisors’ and staff

performance and is positively associated with an environment that emphasizes task

orientation, staff involvement, autonomy and clarity of rules (Eisikovits et al., 1985).

Organizational climate also affects satisfaction with greater levels of trust among

colleagues associated with higher satisfaction in child welfare (Silver et al., 1997).

The influential nature of the supervisory relationship was supported (Hensley, 2002).

Administrative, educational and supportive aspects were valued by supervisees and

seen in behaviours such as availability, delegated responsibility to supervisees who

can undertake a task (Granvold, 1978; York, 1996), are knowledgeable about tasks

and skills (Drake & Washeck, 1998; Himle, et al., 1989), are able to relate techniques

to theory (Drake & Washeck, 1998), provide instrumental support (Himle et al., 1989)

and serve as a role model (Drake & Washeck, 1998; Hensley, 2002). General support

was associated with higher worker satisfaction (Newsome & Pillari, 1991; Rauktis &

Koeske, 1994). Workers were more satisfied when they perceived supervisors’ use of

authority as based on their knowledge and skill rather than their middle manager

role (Munson, 1993) and when supervisors communicated in a mutual style (Bowers,

et al., 1999; York & Denton, 1990).

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Barker, R.L. (1995). Social work supervision. In Social Work Dictionary. Washington, DC: NASW Press.

Barretta-Herman, A. (1993). On the development of a model of supervision for licensed social work

practitioners. The Clinical Supervisor, 11 (2), 55–64.

Berger, C. & Mizrahi, T. (2001). An evolving paradigm of supervision within the changing health care

environment. Social Work in Health Care, 32 (4), 1–18.

Bernard, J.M. & Goodyear, R.K. (2004). Fundamentals of clinical supervision (3rd ed.). Boston, MA:

Pearson.

Bogo, M. & McKnight, K. (2005). Clinical supervision in social work: A review of the research literature.

The Clinical Supervisor, 24 (1/2), 49–67.

Bowers, B., Esmond, S. & Canales, M. (1999). Approaches to case management supervision.

Administration in Social Work, 23 (1), 29–49.

Bruce, E.J. & Austin, M.J. (2000). Social work supervision: Assessing the past and mapping the future.

The Clinical Supervisor, 19 (2), 85–107.

Drake, B. & Washeck, J. (1998). A competency-based method for providing worker feedback to CPS

supervisors. Administration in Social Work, 22 (3), 55-74.

Eisikovits, Z., Meier, R., Guttman, E., Shurka, E. & Levinstein, A. (1985). Supervision in ecological context:

The relationship between the quality of supervision and the work and treatment environment. Journal

of Social Service Research, 8 (4), 37–58.

Erera, I.P. & Lazar, A. (1994). The administrative and educational functions in supervision: Indications of

incompatibility. The Clinical Supervisor, 12 (2), 39–56.

Gibelman, M. & Schervish, P. H. (1995). Pay equity in social work: Not! Social Work, 40 (5), 622–629.

Gibelman, M. & Schervish, P.H. (1997). Supervision in social work: Characteristics and trends in a changing

environment. The Clinical Supervisor, 16 (2), 1–15.

Gleeson, J.P. & Philbin, C.M. (1996). Preparing caseworkers for practice in kinship foster care:

The supervisor’s dilemma. The Clinical Supervisor, 14 (1), 19–34.

Granvold, D.K. (1978). Training social work supervisors to meet organizational and worker objectives.

Journal of Education for Social Work, 14, 38–45.

Hensley, P.H. (2002). The value of supervision. The Clinical Supervisor, 21 (1), 97–110.

Himle, D.P., Jayaratne, S. & Thyness, P.A. (1989). The buffering effects of four types of supervisory

support on work stress. Administration in Social Work, 13 (1), 19–34.

Kadushin, A. (1976). Supervision in Social Work. New York, NY: Columbia University Press.

Kadushin, A. & Harkness, D. (2002). Supervision in Social Work (4th ed.). New York, NY: Columbia

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Munson, C.E. (1993). Clinical Social Work Supervision (2nd ed.). Binghamton, NY: Haworth Press.

Munson, C.E. (2002). Handbook of Clinical Social Work Supervision (3rd ed.). Binghamton, NY: Haworth

Press.

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Conceptualization of Clinical Supervision: A Review of the Literature

Newsome, M. & Pillari, V. (1991). Job satisfaction and the worker/supervisor relationship. The Clinical

Supervisor, 9 (2), 119–129.

Rauktis, M.E. & Koeske, G. F. (1994). Maintaining social worker morale: When supportive supervision is

not enough. Administration in Social Work, 18 (1), 39–60.

Shulman, L. (1993). Interactional Supervision. Washington, DC: NASW Press.

Shulman, L. (2005). The clinical supervisor-practitioner working alliance: A parallel process. The Clinical

Supervisor, 24 (1/2), 23–47.

Silver, P.T., Poulin, J.E. & Manning, R.C. (1997). Surviving the bureaucracy: The predictors of job

satisfaction for the public agency supervisor. The Clinical Supervisor, 15 (1), 1–20.

Tsui, M.S. (1997). Empirical research on social work supervision: The state of the art 1970–1995.

Journal of Social Service Research, 23 (2), 39–51.

York, R.O. (1996). Adherence to situational leadership theory among social workers. The Clinical Supervisor,

14 (2), 5–24.

York, R.O. & Denton, R.T. (1990). Leadership behavior and supervisory performance: The view from below.

The Clinical Supervisor, 8 (1), 93–108.

NURSING

Scholars in nursing practice have noted that the multiple definitions, models and

organizational structures create more confusion than clarity in understanding clinical

supervision (Clearly & Freeman, 2005; Cutcliffe & Lowe, 2005; Jones, 2003; Kelly et al.,

2001; Yegdich, 1999).

Definitions

Clinical supervision in nursing means different things to various organizations and

the people they employ (Rizzo, 2003) and it becomes difficult to find one definition

that captures all the key elements (Cutcliffe & Lowe, 2005). Butterworth and Faugier

(1992) define clinical supervision as “an exchange between practicing professionals

to assist the development of professional skills” (p. 12). Clinical supervision is also

defined as “a practice-focused professional relationship involving a practitioner

reflecting on practice, guided by a skilled supervisor” (UKCC 1996, p. 4).

Jones (2005) reviewed research literature on clinical supervision and credits Winstanley

and White (2003) with the most comprehensive definition: “focusing upon the

provision of empathetic support to improve therapeutic skills, the transmission of

knowledge and the facilitation of reflective practice. The participants have an opportunity

to evaluate, reflect, and develop their own clinical practice and provide a

107


support system to one another” (p. 8). She further identifies the following aspects of

supervision that have achieved agreement by nurse educators:

• It is a formal growth-focused relationship.

• It provides an opportunity for the supervisor to review the professional

development of a new practitioner.

• It provides a forum for discussing the practice of care.

• It allows colleagues to learn from and encourage each other.

• It reduces professional isolation, emotional strain and stress.

• It may lead to the development of practice theory. (Jones, 2005)

She adds that clinical supervision in the United States is also known in clinical

settings as “the relationship between the nursing staff and an administrative clinical

staff member. This relationship is primarily supportive and evaluative in function

and does not meet the criteria for clinical supervision as defined in the UK” (p.149).

In summary, these definitions, though varied, describe a process in which the supervisee

and the supervisor discuss issues related to the supervisee’s practice, development

and, to some extent, performance.

Models

Clinical Supervision Handbook

Sloan (1999) notes that there is no one model of supervision that can deal with the

diversity of clinical needs found in nursing. Differences in definition, models and

the practice of clinical supervision reflect cultural differences between countries,

organizations and nursing specialties. They also reflect differences between North

American and European conceptualizations of clinical supervision.

In North America, clinical supervision refers to relationships between an administrator

or a superior and a more junior supervisee with the supervisor having supervisory

responsibility for the performance of the supervisee (Cutcliffe & Lowe, 2005).

In Europe, clinical supervision emphasizes professional development and support

for the practitioner (Gilmore, 2001). It also focuses on supervisee-led issues that

range from patient care to interpersonal issues with peers (Cutcliffe & Lowe, 2005).

Similarly Jones (2005) refers to the U.K. model as a mandatory reflective practice

between the supervisee and the supervisor, while in the United States, the model

refers more to a relationship between an expert supervisor and a novice or new

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Conceptualization of Clinical Supervision: A Review of the Literature

nurse supervisee.

Additionally Jones (2005) identifies the three models of clinical supervision found in

the nursing literature:

• the growth model and support model (Faugier, 1992)

• the integrative approach (Hawkins & Shohet, 1989)

• the three function-interactive model (Proctor, 1986).

Growth model

In the growth model, the supervisor facilitates growth both educationally and personally,

assisting in developing clinical autonomy in the supervisee. The focus is on the

relationship aspect of clinical supervision and includes mentorship (Faugier, 1992).

Integrative model

The integrative model divides supervision into four components: supervisor, supervisee,

client and work context. The supervisor and supervisee develop a contract with

negotiated shared tasks and goals (Hawkins & Shohet, 1989).

Three-function interactive model

Proctor’s (1986) three-function interactive model is based on a normative or managerial

function, which promotes and complies with organizational policies. Educational

supervision encompasses activities that develop the professional capacity of supervisees,

including teaching knowledge and skills, and developing self-awareness (Barker, 1995;

Munson, 2002) through, for example, teaching, case consultation, facilitating learning

and growth. This educational component and the restorative or pastoral support

function help the nursing practitioner to understand and manage the emotional

stress of nursing practice.

In the ideal working environment, these models of clinical supervision present benefits

for nursing practice. For instance, several studies have shown that nursing staff

who access clinical supervision acquire a greater readiness to act as well as a greater

openness to change attitudes and outlooks when it comes to:

• solving problems that arise in care relations (Begat et al., 1997; Magnusson et al.,

2002)

• co-ordinating their responses with others (Jones, 2003)

• experiencing greater job satisfaction (Arvidsson et al., 2001; Hyrkäs, 2006)

• improving creativity and organizational climate (Berg & Hallberg, 1999).

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Toward an evidence-base for clinical supervision in nursing

Does the research on clinical supervision in nursing provide evidence to support the

diverse conceptualizations? Two reviews of the empirical research on clinical supervision

in nursing, one spanning 1990–1999 (Williamson & Dodds, 1999), and the other

spanning 1996–2004 (Jones, 2005) found that different aspects of clinical supervision

are widely studied and described in the nursing literature. This growing interest in

clinical supervision, however, derives mainly from Europe (U.K. and the Scandinavian

countries) and from Australia and New Zealand. There is a paucity of research from

North America (Cutcliffe, 2005; Jones, 2005). The studies reviewed employ surveys

and exploratory interviews with descriptive and systematic qualitative designs and

have begun to contribute to an empirical base. However, investigators note that these

studies address the concept of clinical supervision in nursing while lacking a consensus

about the definition of the term or its components (Yegdich, 1999).

The existing studies contribute to the formation of a definition and all provide

support for its utility. For example, Kelly and colleagues (2001) found that managers

(87.5 per cent), supervisors (85.2 per cent), and the great majority of clinical

psychiatric nurse respondents supported the view that supervision can lead to

personal development.

Studies examined the process of clinical supervision. In one study, it was found that

a focus on the nurse “doing” (defined as the nurse-patient relationship) and not on

the nurse “being” (defined as the nurse as a person) made it easier for nurses to talk

about their feelings and actions (Berg & Hallberg, 1999). A number of studies found

that clinical supervision helps nurses gain knowledge and competence, a sense of

security in nursing situations, and a feeling of personal development (Arvidsson et al.,

2001; Jones, 2003; Magnusson et al., 2002). Additionally, Arvidsson and colleagues

(2001) found that supervision gave nurses a sense of feeling independent, increased

energy, fellowship with others and greater job satisfaction.

Format of clinical supervision

The format of clinical supervision has been investigated by a number of researchers.

In a study of nurses in an acute inpatient mental health setting, Cleary and Freeman

(2005) found nurses preferred ad hoc coping methods such as informal sharing and

support of trusted colleagues rather than a more formal approach. These nurses felt

that one-on-one clinical supervision was impossible due to unit constraints. Clinical

supervision in open groups was difficult to arrange due to staff leaves, rotations and

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Conceptualization of Clinical Supervision: A Review of the Literature

skill mix. In contrast, Kelly et al., (2001) found that one-on-one clinical supervision

was the commonly adopted approach by three-quarters of their sample of nurses

in Northern Ireland. Group supervision was offered to only seven per cent of nurses

surveyed.

Factors contributing to quality of supervision

In investigating the factors that contribute to the quality of supervision, Berg and

Hallberg (1999) found that quality depended on the supervisor’s ability to encourage

and create a permissive atmosphere while Kelly and McKenna (2001) identified the

importance of training. They found that 100 per cent of managers and more than

90 per cent of supervisors and clinical psychiatric nurses strongly supported the

need for supervisor training. They also found an overwhelming majority of all

participants agreed that managers are not the best supervisors.

Rafferty, and colleagues (2003) used a modified Delphi method with expert clinical

supervisors to elicit their perceptions about the multi-dimensional aspects of clinical

supervision and to achieve some consensus about crucial components. They found

three main factors that contribute to effective supervision:

• professional support

• learning

• accountability.

Professional support refers to use of time, supervisory environment and mutuality in

the relationship. Supervisors demonstrated the value of supervision by maintaining

appointment times and defining supervision as part of the work. A positive supervisory

environment was defined as offering consistency, comfort, privacy and the absence

of inappropriate distractions. Relationships were built on mutual respect, choice and

negotiation of ground rules.

The second factor is learning, which refers to focus, knowledge and interventions.

Supervisors assist supervisees to articulate, reflect and make meaning of their activities,

which promotes safety and effective nursing care. Knowledge is enhanced when

supervisors elicit explanations and identify supervisees’ abilities and needs for professional

development, when they affirm appropriate practice, support professional

esteem, and encourage the continual need for achievable challenges.

The third factor is accountability, which refers to organizational support, recording,

and competency. The organization must provide the commitment and resources

to enable supervisees and supervisors to receive or offer appropriate supervision.

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A competent supervisor is conscientious about recording processes that specify

content, about knowing who has a right to access information, and recognizing what

constitutes good practice. The maintenance of personal reflective diaries enabled

supervisors to define their own needs for supervision, clarify expectations, and

further develop their skill in supervision.

In summary, clinical supervision researchers in nursing conclude that clinical supervision

is necessary for safe and effective nursing practice and can lead to personal

and professional development (Arvidsson, et al., 2001; Berg & Hallberg, 1999; Kelly

& McKenna, 2001; Rafferty et al., 2003). Nurses, managers and supervisors agree

that the process and format vary depending on the organizational context in which

clinical supervision takes place (Arvidsson, et al., 2001; Berg & Hallberg, 1999;

Jones, 2003; Kelly & McKenna, 2001). Commonly identified elements are:

• positive interpersonal relationships

• affirmation of appropriate practice

• deliberate scheduling of time and space

• reflection and provision of specific applied knowledge

• organizational support

• staff accountability.

CONCLUSION

A comparison of the social work and nursing literature on clinical supervision reveal

common elements in the approaches offered by Kadushin’s model of three interrelated

functions of social work supervision and Proctor’s three-function interactive model

of nursing supervision. Both models of supervision include an administrative,

supportive and educational component that can lead to increased accountability

and feelings of personal support.

A significant difference between social work and nursing supervision is the lack of

consensus about the definition of clinical supervision in nursing. What is more,

the logistical realities of nursing, including time away from clients, rotating shifts,

24-hour care and stringent time-oriented duties make it challenging to implement

clinical supervision within a nursing environment. By comparison, in many social

work agencies, the daily activities of social work are exempt from many of these

constraints and offer an environment more conducive to regularly scheduled clinical

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Conceptualization of Clinical Supervision: A Review of the Literature

supervision sessions. Finally, social work has a long history of valuing clinical supervision

as the crucial vehicle for professional development of the social worker. By

contrast, in nursing, it appears from the literature that clinical supervision is more

frequently viewed as an authoritarian and hierarchical activity that arises in response

to an error or indiscretion.

References

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and Hall.

Cleary, M. & Freeman, A. (2005). The cultural realities of clinical supervision in an acute inpatient

mental health setting. Issues in Mental Health Nursing, 26, 489–505.

Cutcliffe, J.R. (2005). From the guest editor—Clinical supervision: A search for homogeneity or

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United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1996). Position statement

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Williamson, G.R. & Dodds, S. (1999). The effectiveness of a group approach to clinical supervision in

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Journal of Advanced Nursing, 30 (5), 1195–1204.

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APPENDIX 2

Evaluation For a

Clinical Supervision Group

PART A

YES NO

Are you currently in supervision elsewhere? ■ ■

If yes, how long have you been in supervision elsewhere? ■ ■

How many times have you attended the clinical supervision group? ■ ■

PART B

YES YES NO

DEFINITELY SOMEWHAT

1. The clinical supervision group has helped ■ ■ ■

improve my clinical practice.

If yes, please elaborate on how the clinical supervision group has helped your clinical

practice…

YES YES NO

DEFINITELY SOMEWHAT

2. The clinical supervision group makes me

feel more supported in my practice.

■ ■ ■

3. Through the clinical supervision group,

I have learned new ways to approach practice.

■ ■ ■

4. The clinical supervision group has increased

my self-awareness.

■ ■ ■

5. The clinical supervision group has helped me cope

with difficult situations.

■ ■ ■

115


Clinical Supervision Handbook

YES YES NO

DEFINITELY SOMEWHAT

6. The clinical supervision group has helped

me look more objectively at my work.

■ ■ ■

7. Through attending the clinical supervision group,

I have developed skills in providing peer supervision.

■ ■ ■

8. I feel safe participating in the clinical

supervision group.

■ ■ ■

** If you said somewhat or no to the above question, can you suggest some ways that

would improve safety?

Please comment on the following:

9. What do you feel is missing from the clinical supervision group?

10. What advice do you have for the facilitators?

Developed by Kathy Ryan (2005) in consultation with Ruth Gallop

116


APPENDIX 3

CLINICAL SUPERVISION CONTRACT

DATE: _______________________________

As clinician and clinical supervisor, we agree to the following:

• to work together to facilitate in-depth reflection on issues affecting

practice, so developing both personally and professionally to develop

a high level of clinical expertise.

• to meet on average once per week as a group for one hour.

• to protect the time and space for clinical supervision, by keeping to

agreed appointments and time boundaries. Privacy will be respected

and interruptions avoided.

• to provide a record for our employer, showing the times and the dates

of the clinical supervision sessions.

• We will work to the clinician’s agenda, within the framework and focus

negotiated at the beginning of each session. However, the clinical

supervisor reserves the right to highlight items apparently neglected

or unnoticed by the clinician.

• We will work respectfully, both of us being open to feedback about

how we handle the clinical supervision sessions.

We both agree to challenge aspects of this agreement that may be

in dispute.

As a clinician I agree to:

• prepare for the sessions, for example, by having an agenda or

preparing notes, videos, observation opportunities, audiotapes.

• take responsibility for making effective use of the time (including

punctuality), the outcomes and any actions I may take as a result

of clinical supervision.

• Be willing to learn, to develop my clinical skills and be open to

receiving support and challenge.

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continue next page...


As a clinical supervisor I agree to

• Keep all information you reveal in the clinical supervision sessions

confidential, except for these exceptions:

– You describe any unsafe, unethical, or illegal practice that you are

unwilling to go through the appropriate procedures to address.

– You repeatedly fail to attend sessions.

• In the event of an exception arising, I will attempt to persuade and

support you to deal appropriately with the issue directly yourself.

If I remain concerned, I will reveal the information only after informing

you that I am going to do so.

• At all times work to protect your confidentiality.

• Not allow procedural issues of the work to monopolize the clinical

supervision session.

• Offer you advice, support, and supportive challenge to enable you

to reflect in depth on issues affecting your practice.

• Be committed to continually developing myself as a practicing

professional.

• Keep a record of our clinical supervision sessions.

• Ask for feedback for the purpose of evaluating the clinical supervision

process.

• Use my own clinical supervision to support and develop my own

abilities as a clinical supervisor and clinician, without breaking

confidentiality.

Anything else?

Frequency of Meetings

Venue

Duration of Clinical Supervision Relationship

Next Review Date

Clinical Supervision Handbook

Signed Signed

(Clinician) (Clinical Supervisor)

Thank you for completing this questionnaire!

Adapted from Bolton Primary Care Trust (2003). Clinical Supervision Guidance Document. Available at

www.bolton.nhs.uk/foi_pubscheme/policy_store. Accessed January 15, 2008

118


APPENDIX 4

Core Clinical Practice Competencies

This document has been developed to articulate the practice competencies required

by camh clinicians of all professional disciplines. Each discipline has unique

domains and standards of practice determined by a regulatory body and/or professional

association. All camh clinicians must maintain membership in good standing

in their college or professional association. This document is offered as a guide to

the essential competencies required of all professionals in the organization. Other

documents such as the camh Code of Conduct, camh Leadership Profile and camh

Values and Mission Statement also delineate expectations of camh staff. This document

is specifically intended for use by camh clinicians to improve clinical practice and

client care. It may act as a framework by which camh clinicians develop learning plans,

monitor practice, set career milestones, and create professional development goals. It

may also act as a guideline for reviewing competency at each level of development.

Additionally, it may be used by:

• camh staff involved in orientation of students and new staff

• clients and other people using camh services to better understand the various

levels of practice of camh clinicians

• apn /apc / discipline chiefs and program managers to create a context for guiding

and evaluating the practice of supervisees

• camh administrators to effectively distinguish, maintain and further refine

standards of practice of camh clinicians, and to support them in the hiring and

retention of individuals with the necessary knowledge and skills required to

meet the needs of clients.

This document has been organized along a continuum of practice in order to

acknowledge that clinicians acquire knowledge and skills over time and that practice

matures in recognizable and definable ways. In domains of practice common to all

mental health and addictions professionals—therapeutic relationships, assessment,

119


intervention, evaluation, professionalism, collaborative practice—these core

competencies provide common language about job and performance expectations.

Ultimately, the development of these competencies across the organization will ensure

that camh clinicians are current in providing clients with evidence-based practices.

Three distinct levels of practice are delineated and each level coincides with the

development of practice as clinicians continue to gain skill, knowledge and professional

wisdom. It is possible that one may practice at a higher or lower level in certain

domains but the level of practice is defined by where one most consistently practices,

keeping all areas in mind. The same levels are for use across disciplines, and each

discipline has its own body of work and expertise, so the skills and behaviours practised

at each level will be different for each discipline. Each level of practice builds upon the

previous one, with increasingly greater competency, proficiency and excellence in the

breadth and depth of practice. It is also written in such a way that each clinical program

can adapt it more specifically to the particular needs of their client population.

LEVELS OF PRACTICE

The levels of practice identified here are:

• competent practice

• proficient practice

• expert practice.

Competent practice

Competent practice is characterized by entry-level clinical knowledge and skill by

a clinician who has completed an accredited educational program of study. The

competent clinician requires ongoing clinical supervision in order to become

proficient in specific knowledge and skill areas.

Proficient practice

Clinical Supervision Handbook

Proficient practice is characterized by specialized clinical knowledge and skill whereby

the clinician is practising at an autonomous or intermediate level (typically three

years of experience in a specialized mental health/addiction field). The proficient

clinician is a recognized role model, student preceptor, clinical resource and leader

demonstrating clinical mastery and commitment to achieving program goals while

continuing to seek improvement through clinical supervision or consultation.

120


Expert practice

Expert practice is characterized by the ability to lead, direct, support and influence

clinical practice within the organization. This clinician possesses intuition and has

developed a specialized knowledge and skill level that is grounded in higher education

and practical experience (typically five or more years). The expert clinician teaches,

supervises and consults with other members of the health care team. He or she takes

on an active part in the achievement of program goals.

NOTE: The term “client” is used to inclusively refer to individuals and their families,

groups or communities serviced by camh clinicians. However, the “client” of the

expert clinician is often clinical staff functioning at competent and/or proficient levels

of practice or the organization itself. “Family” is whoever the client determines his

or her family to be.

DOMAINS OF PRACTICE

The following chart outlines the domains of practice required for clinicians at

camh. The domains are:

• clinician-client relationship

• family and social support

• professional autonomy and accountability

• embracing cultural diversity

• clinical assessment: interviewing, formulation, treatment planning and

documentation

• therapeutic interventions with clients, groups and families: practice,

documentation and case management

• anticipation and responding to rapidly changing situation

• program development, implementation and evaluation of care

• outreach

• teamwork, collaboration and partnerships

• ethical, organizational and legal accountabilities

• professional development and research

• consultation and education

Core Clinical Practice Competencies

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Clinical Supervision Handbook Core Clinical Practice Competencies

CORE CLINICAL PRACTICE COMPETENCIES

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Proficient Expert

Possesses expert knowledge,

skill and intuition and applies

the competency in the most

complex situations at various

levels within and across the

organization

Possesses specialized, advanced

clinical knowledge and skill and

practices autonomously across

a wide range of increasingly

complex clinical situations

Competent

Possesses entry-level clinical

knowledge and skill and has

knowledge and skill to implement

the competency in routine

practice in a variety of clinical

situations

DOMAIN OF PRACITCE LEVEL OF PRACTICE

• Engages in and role-models

excellence in therapeutic

relationships with clients as

well as professional relationships

with supervisees and

other staff

• Demonstrates high level of

self-awareness and able to not

only acknowledge own personal

• Demonstrates mastery in

effectively engaging in, maintaining

and terminating

therapeutic relationships

• Models therapeutic relationships

with clients and demonstrates

the same principles in

relationships with students,

staff and larger systems

• Understands that the therapeutic

relationship between

clinician and client is foundational

to effective mental

health and addiction practice

• Facilitates therapeutic relationships

with clients that:

– focus on trust, respect,

compassion, empathy and

Clinician-Client Relationship

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Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

values, transference/countertransference

and, parallel

process issues and respond

accordingly but also intuitively

anticipates the same

• Effectively demonstrates

differential use of self in

therapeutic relationships

• Fosters, and consistently

monitors, the environment to

ensure that clients and

clinicians are safe from abuse

• Provides ongoing training and

clinical supervision to assist

and support staff in engaging

in effective therapeutic relationships

following the guidelines,

values and principles

outlined in the camh Clinical

Supervision handbook

• Provides debriefing after

critical incidents involving

clinicians and clients

• Seeks consultation with

colleagues as needed

• Demonstrates high level of

self-awareness and an ability

to respond effectively to

transference and countertransference

issues

• Promptly and effectively

addresses any inequitable or

discriminatory behaviours

toward clients, families and

others at camh

• Advocates on behalf of the

client and champions camh

Bill of Client Rights

• Provides guidance, support,

knowledge and skills to staff

and students in understanding,

creating and maintaining

therapeutic relationships

• Seeks supervision as needed

regarding to clinician-client

relationship issues

client strengths

– promote and provide biopsychosocial-spiritual

and

cultural comfort and

sensitivity to clients

– protect client confidentiality

– respect client autonomy,

dignity, privacy and rights

• Demonstrates self-awareness

of his or her beliefs, values,

social location and culture

and their influence on therapeutic

relationships

• Responds appropriately when

differences arise between self

and clients from diverse

groups

• Ensures that appropriate

boundaries between professional

therapeutic relationships

and non-professional

personal relationships are

maintained

• Recognizes when triggers

Clinician-Client Relationship

continued

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Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

regarding staff-client issues

that arise with supervisees or

with own clients

occur (e.g., own “buttons”

are pushed) and responds

appropriately seeking supervision

as necessary

• Assumes a wellness and

recovery perspective

• Creates a safe, respectful and

caring environment for clients

• Communicates with respect

• Uses language that is nonstigmatizing.

• Seeks out guidance, support,

knowledge, skills and regular

supervision with respect to

therapeutic relationships and

clinical work

Clinician-Client Relationship

continued

124


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

Family and Social Support • Understands the impact of • Has a comprehensive knowl- • Recognized as an expert in

family functioning on mental edge of family systems theory, one or more models of family

health/illness/addictions

family process, dynamics and therapy practice

• Values and appropriately

functioning

• Provides family therapy

includes family and social • Understands the impact of training and supervision

support systems in the

illness on family functioning across the Centre and at

assessment, planning and and family functioning on local, provincial and national

treatment of client care

illness

forums

• Is able to assess family needs • Conducts family assessments

and how best to involve them using evidence-based models

in the client’s care

• Purposefully works with client

• Shares knowledge of commu- and family to enhance family

nity supports and resources functioning and cohesion

for families with a member using evidence-based family

experiencing mental health therapy models

and/or addiction problem(s) • Able to provide treatment that

• Seeks out family therapy

emphasizes family as the unit

training and supervision

of care

• Supervises others in family

therapy

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Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Uses standards of practice,

legislation, ethical and legal

knowledge to clarify scope of

practice for self and others

• Anticipates factors that may

interfere with professional

autonomy of staff situation

(i.e., staffing ratios, low staff

morale) and seeks to remedy

• Shares and models dissemination

of evidence-based

practices to continuously

improve outcomes for clients

and families experiencing

mental health and / or

addiction problems

• Displays strong leadership

skills within the program,

organization and community

to influence the profession,

mental health and addiction

health care, and the provincial

health care system

• Monitors, refines and advances

standards of practice in his or

her profession and program

• Shares knowledge and expertise

with other clinicians and

students to meet client need

• Informs competent staff

and students of resources

available to support their

practice, consolidation and

development

• Displays initiative for new

ideas within the program and

organization

• Works within program,

organization and community

to decrease stigma associated

with mental health and

addiction

• Works autonomously and

makes clinical decisions seeking

supervision appropriately

as needed

• Understands her or his scope

of practice, and seeks timely

assistance from proficient

and expert clinicians

• Recognizes and embraces

the importance and value of

helping relationships

• Demonstrates a commitment

to helping clients and families

achieve their goals

• Practises honesty, dignity,

respect, compassion and

integrity with each individual

and family

• Honours and maintains client

and family confidentiality

• Understands the influence of

stigma on clients and supports

clients and family who feel

stigmatized

• Maintains competency and

refrains from activities

in which he or she is not

competent

Professional Autonomy

and Accountability

126


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Has comprehensive and

detailed knowledge and skill

in working with diverse populations

and applies to program

planning and evaluation

• Is a recognized expert in

diversity training and provides

consultation to specialized

populations, colleagues and

other health care professionals

who are learning to implement

culturally sensitive care

• Possesses extensive knowledge

of diversity issues and

delivers culturally sensitive

care to individuals, agencies

and communities

• Mentors colleagues in diversity

training

• Helps diverse client populations

to implement programs

in their communities

• Understands, identifies and

responds to issues of diversity

and how they influence client

health and illness

• Incorporates knowledge of

cultural and socio-economic

issues and develops effective

working relationships with

various client populations

within and outside of camh

Embracing Cultural Diversity

• Recognized by others as

expert in assessment

processes

• In own clinical practice and in

supervising others, is able to

take a meta-perspective on

client/family situation and

rapidly synthesize and interpret

multiple levels of data in

complex client and family

assessment situations

• Demonstrates a whole

systems perspective in clinical

interviewing, formulation and

documentation

• Able to independently

conduct family assessments

utilizing a systemic,

strengths-based approach

• Has acquired and applies

substantial knowledge of

clinical assessment process,

• Collaborates with clients and

other members of the health

care team to complete comprehensive

assessments that

consider mental, psychological,

social, spiritual and physical

health

• Demonstrates sensitivity to

client gender and diversity

issues

• Selects, applies and interprets

Clinical Assessment:

Interviewing, Formulation,

Treatment Planning and

Documentation

127


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Applies development research

in evaluating assessment

tools and instruments to

measure clinical outcomes

• Teaches, champions and

advances innovative knowledge

in assessment practices—

interviewing, formulation,

treatment planning and camh

documentation initiatives

(e.g., electronic health record)

• Demonstrates masterful

knowledge, skill and experience

in understanding and enhancing

client motivation

• Demonstrates masterful

knowledge, skill and experience

in developing plans of care in

complex clinical situations

that honour and respect client

goals particularly when goals

of client and family differ

from those of the clinician

• Transfers knowledge and

provides supervision to

measurement tools, and

evidence-based treatments

for clinical population

• Demonstrates advocacy for

clients at a higher organizational

level (e.g., odsp)

• Demonstrates knowledge of

tools for special populations

(e.g., t-ace (screening for

alcohol dependence in

pregnant women)

• Responds to issues of culture

and diversity in a purposeful

manner, building on client

strengths and seeking additional

supports and resources

as needed

• Identifies barriers within the

care delivery process that can

impact on client goals being

achieved

• Designs treatment plans for

complex, sensitive situations

that require substantial

co-ordination between services

evidence-informed screening

and/or assessment tools

• Utilizes cultural assessments

tools

• Understands and utilizes evidence-based

tools appropriate

to the client’s situation (i.e.,

subscribed outcome tools in

treat, mse, dsm iv, ciwa-a

cage and physical examination

including screening for

co-morbidity)

• Understands and takes into

account social determinants

of health (i.e., poverty,

employment, housing, health,

social support, past trauma)

during the assessment

• Understands the influence of

having an addiction on mental

health and of mental health

problems on the development

of an addiction

• Considers concurrent disorders

in assessment:

Clinical Assessment:

Interviewing, Formulation,

Treatment Planning and

Documentation continued

128


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

others, ensuring clinical

integrity in clinical assessment

practices—

interviewing, formulation

and documentation

• Engages with the client and

other resources to adjust the

treatment plan as needed

• Works with staff to help

bridge any gaps between

client goals and clinician

goals for client and develops

strategies to enhance client

motivation

• Coaches and/or mentors

others to ensure clinical

integrity in assessment

processes—interviewing,

formulation, treatment

planning and documentation

• Seeks supervision as needed

with respect to interviewing,

formulation and

documentation

– able to screen for alcohol

and other drug problems,

dependence, symptoms of

withdrawal and intoxication

– able to take a history of

alcohol and drug consumption,

consequences of

alcohol and drug use

(physical and social);

assess sexual practices,

injection drug use, driving

while impaired

• Considers trauma factors

in assessment

• Ensures physical health

issues are included in

assessment

• Assesses clients’ need for

language support

• Formulates an individualized,

comprehensive plan of care

with the client to accurately

respect and reflect the complexity

of client values, preferences,

needs and goals and

Clinical Assessment:

Interviewing, Formulation,

Treatment Planning and

Documentation continued

129


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

that integrates evidencebased

treatment modalities

• Recognizes and respects

clients’ unique differences,

strengths and barriers and

customizes individual plans

of care accordingly

• Determines and shares with

the client the treatment plan,

monitors course of treatment

and assists clients experiencing

setbacks

• Documents client assessments

in a clear, concise and

timely manner on camhapproved

forms (e.g., eIPCC)

and in accordance with camh

documentation policies and

guidelines

• Seeks assistance from experienced

staff in all aspects of

clinical assessment

Clinical Assessment:

Interviewing, Formulation,

Treatment Planning and

Documentation continued

130


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Recognized as an expert in

providing individual, group

and/or family therapy utilizing

most effective evidence-based

approaches in a flexible,

innovative and confident

self-directed approach

• Communicates and models

excellence in client care

• Effectively facilitates group

therapy in which complex

issues arise (e.g., disruptive

behaviours, disengaged members)

and provides others in

the field with group therapy

supervision or published

materials

• Evaluates evidence-based

approaches for mental health

and/or addiction treatment

• Creates a program context

that supports quality practice

• Forms partnerships to facilitate

programs within and

outside of camh

• Has substantial knowledge of

and skills related to client,

group and/or family specific

interventions (e.g.,

Motivational Interviewing,

cbt, dbt, ipt, ccrt, family

therapy)

• Delivers and models above

interventions using a whole

systems perspective

• In group therapy, recognizes

difficult group dynamics and

facilitates discussion to

resolve issues while achieving

group goals

• Demonstrates an ability to

make autonomous clinical

decisions

• Applies a variety of mechanisms

to ensure excellence in

clinical care (e.g., client

satisfaction, accreditation)

• Provides mentorship to staff

with respect to clinical practice,

documentation and case

• Ensures that his or her practice

is grounded in theory and

applies evidence-based practices

to meet specific client

and family mental health

and/or addiction concerns

and needs

• Delivers client-, group- and

family-centred interventions

in a non-judgmental and nondiscriminatory

manner

• Tailors interventions to meet

developmental and cultural

needs of the client and family

• Understands group dynamics

and is able to effectively

facilitate group therapy,

engaging the group while

accommodating needs of

specific individuals

• Understands how to access,

and subsequently provides,

appropriate information and

resources to clients and

families to help them

Therapeutic Interventions with

Clients, Groups and Families:

Practice, Documentation and

Case Management

131


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Ensures resources are available

across the organization

for staff to provide most

effective treatments for clients

• Develops opportunities for

client education and empowerment

and demonstrates

leadership in the field at local,

and national educational

events and programs

• Develops policies and practices

to meet needs of diverse

populations

• Sets standards of excellence

for client care

• Develops, modifies and

evaluates camh documentation

policies, practices and

forms to continuously

improve client and family care

management issues

• Forms partnerships with

community groups

• Seeks supervision as needed

with respect to clinical practice,

documentation and case

management

participate in and/or make

informed decisions about

their care and treatments

• Advocates on behalf of client;

shares knowledge of advocacy

resources available to clients

and families internally and

externally

• Supports family members

• Seeks supervision or

resources / evidence needed

to inform safe, effective clinical

practice

Therapeutic Interventions with

Clients, Groups and Families:

Practice, Documentation and

Case Management continued

132


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Takes leadership in developing,

modifying and evaluating

policy and practice guidelines

regarding to emergency codes

• Explicitly identifies, anticipates

and foresees an emergency

code (e.g., client appearing

aggravated and becoming

increasingly defiant) and

prevents it from occurring

with de-escalation strategies

• Provides debriefing and

supervision to staff after critical

incidents (i.e., code white,

code Blue) involving staff

and clients

• Regularly analyses code

functioning with team

• Invites external perspectives

on risk assessment and

mitigating strategies

• Provides leadership, intervention

and support in all camh

emergency codes

• Supports and educates staff

and students according

emergency codes

• Modifies environment to

minimize occurrence of codes

(e.g., triggers to a code white)

• Continuously assesses and

anticipates psychiatric emergencies

(e.g., self harm, harm

to others) within specified

client population using

evidence-based tools

• Recognizes symptoms and

risk of withdrawal from

alcohol and / or drugs and

responds in a timely manner

using evidence-based

protocols

• Analyzes and interprets

unusual client responses and

responds in a timely manner

• Creates and documents

safety plans

• Recognizes role in a code

white and for nursing staff,

or a code blue

• Familiar with policies and procedures

related to emergency

responses (e.g., codes blue,

white, red) and participates in

educational opportunities on

Anticipating and Responding to

Rapidly Changing Situations

133


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

these codes

• Demonstrates ability to intervene

appropriately with

clients assessed to be at risk

of harm to self or others

• Seeks immediate assistance

in rapidly changing situations

that exceed level of competence

or confidence

Anticipating and Responding to

Rapidly Changing Situations

continued

• Leads team in program development,

implementation and

evaluation across programs,

camh as an organization

and within the community

• Acts as leader for camh in

addressing gaps for specialized

populations at local,

provincial or national level

and incorporates findings

into ongoing program

development

Proficient

• Demonstrates global perspective

on developing, implementing

and evaluating client

care programs

• Leads team and supervises

others in generating ideas for

new programs or modifying

existing ones, and in implementing

and evaluating

programs

• Collaborates effectively with

colleagues involved in the

Competent

• Recognizes, respects and

validates client and family

goals in the development,

implementation and evaluation

of camh approaches

to care

and programs

• Identifies need for refining

current approaches to care

and/or for developing new

approaches or programs

of care

Program Development,

Implementation and Evaluation

of Care

134


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Is a recognized expert

and leader in program

development, planning

and evaluation

program development and

evaluation

• Applies knowledge of

research methodologies in

analysing data

• Independently writes reports

related to program changes,

development of new programs

and evaluation of programs

• Plans and implements new

programs and utilizes analytical

skills to evaluate them

• Evaluates outcomes of treatment

in light of client and

health care team goals and

modifies plans with client and

team accordingly

• Contributes to reports related

to modifying or designing

new approaches or programs

Program Development,

Implementation and Evaluation

of Care continued

• Is a recognized expert for

designing outreach programs

for specialized populations

• Identifies gaps in outreach

programs and collaborates

with community partners to

improve and modify existing

programs or create new ones

• Provides supervision and

leadership across camh and

supports programs to be

delivered within communities

• Delivers a variety of evidencebased

outreach services in

the community

• Supports and supervises

others to design and deliver

culturally sensitive outreach

services

• Demonstrates good understanding

of outreach needs

in a community within

specialized population

• Participates in program delivery

and evaluation of culturally

sensitive outreach programs

based on evidence-based

practices

• Seeks out necessary supervision

in delivering and

evaluating outreach programs

Outreach

135


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Creates a team culture that

facilitates collaboration on

multiple dimensions within

multiple systems to improve

client care

• Teaches, coaches and mentors

staff and draws forth their

strengths

• Offers supervision that is consistent

with qualities of a

supervisor-supervisee relationship

as outlined in the camh

Clinical Supervision Handbook

• Creates opportunities to

develop clinicians into leaders

• Possesses community development

skills and pursues

partnerships with other internal

and external providers

• Fosters innovation, creativity

and commitment to organizational

change

• Builds partnerships with

various levels of government

to champion the agenda of

camh

• Possesses excellent understanding

and demonstrates

skill related to effective team

dynamics and functioning

• Successfully assists staff to

manage conflicts that arise

within the team

• Shares information directly

and openly and will engage in

difficult conversations

• Builds teams that work well

together, experience trust,

openness and flexibility

• Creates team context that

effectively addresses conflict

and ambiguity

• Works with team differences

to develop a stronger, more

effective team

• Addresses power dynamics

• Demonstrates knowledge of

the roles of various members

of the team

• Displays initiative, works collaboratively

within the team,

asks questions, exercises

professional judgment and

seeks consultation as needed

• Recognizes potential for conflict

and applies basic conflict

resolution strategies

• Possesses knowledge and

skill in professional communication,

leadership and

negotiation strategies

• Works positively within team

to effectively transform situations

of conflict into healthier

interpersonal interactions

• Demonstrates good understanding

of team and group

dynamics

• Embraces and behaves in

accordance with camh values

and strategic direction

Team Work, Collaboration and

Partnerships

136


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Recognized as an expert in

ethics in the field of mental

health and addiction

• Collaborates with other health

care professionals to challenge

and co-ordinate institutional

resources to achieve the most

effective outcomes

• Creates environments within

camh and with external partners

that promote safe, ethical,

legal, professional practice

and deals effectively with staff

and/or clients when ethical

issues arise

• Leads accreditation and quality

improvement initiatives at

organizational level and in

collaboration with camh

external partners

• Represents camh externally

(e.g., committees, media,

community development

projects) as a leader in a

• Advocates for the best possible

care for clients, for her or

his profession and for the

health care system

• Engages self and staff in critical

thinking about identifying and

resolving ethical issues,

concerns and dilemmas

• Works with camh partners to

ensure compliance to standards

of professional, ethical

practice

• Creates manageable staff

workload and scheduling for

staff giving them sufficient

time to discuss and plan care

with colleagues

• Leads accreditation and quality

improvement initiatives at

program level

• Represents program and / or

camh in internal / external

committees

• Has a strong working knowledge

of legislation in caring

• Identifies and understands

ethical concerns, issues and

dilemmas as they pertain to

the client-clinician relationship

and to the larger field of

mental health and addictions

• Demonstrates knowledge of

the implications of ethical issues

in interactions with clients

experiencing mental health

and/or addiction problems

• Collects and uses available

resources from various

sources to resolve ethical

issues

• Has a good working knowledge

of ethics and is able to

make ethical decisions

• Is knowledgeable about camh

values, policies, procedures,

program specific initiatives

and strategic directions

• Demonstrates awareness

of relevant legislation that

guides practice

Ethical, Organizational and

Legal Accountabilities

137


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

specialized field of mental

health and / or addiction

practice and / or research

for clients and families in his

or her specialized mental

health and / or addictions

field

• Ensures client safety and

protects the client from abuse;

reports unsafe practices

• Organizes workload and

develops time management

skills to meet responsibilities

• Integrates quality improvement

initiatives into practice

• Completes all required workload

measurements in a timely,

professional manner

• Completes documentation

in accordance with camh

standards

• Displays commitment to

continuous quality improvement

(i.e., cqi, InfoMed)

• Participates in program and

camh internal/external

committees

Ethical, Organizational and

Legal Accountabilities continued

138


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Independently monitors and

evaluates his or her own practice,

professional development

needs and goals, and need for

clinical consultation/supervison

• Develops, facilitates and

implements learning activities

to promote professional

development of all interdisciplinary

staff members

• Provides constructive feedback

and recognition of

accomplishments to staff

• Critically analyses program

practice and makes recommendations

at program and

senior administration level for

improvement

• Leads team in evaluation of

practice through research and

application of current outcome

measures and development

of population-specific ones

• Actively develops proposals

for funding

• Assumes responsibility for

monitoring her or his own

needs with respect to professional

development and seeks

out supervision and consultation

as needed

• Provides competent staff and

students with feedback that

encourages professional

growth

• Demonstrates mastery in

evaluation of practice, utilization

and dissemination of

research

• Engages in research by

critiquing research reports

• Takes leadership role in

clinical research activities

(e.g., literature searches,

subject recruitment, pre /

post testing, report writing)

• Conducts internal and external

presentations of clinical

work and / or research

• Identifies opportunities for

continued professional development

that correspond with

personal career goals

• Seeks out and receives clinical

supervision on a regular basis

consistent with the value of

lifelong learning

• Engages in reflective practice

and completes annual selfevaluation

(padr) with

Program Manager and / or

Program apn/apc/discipline

Chief

• Utilizes research and identifies

research opportunities

Professional Development and

Research

139


Clinical Supervision Handbook Core Clinical Practice Competencies

DOMAIN OF PRACITCE LEVELS OF PRACTICE

Competent Proficient Expert

• Participates in the ethical

review of research ensuring

that ethical guidelines are

followed to protect research

participants and investigators

• Publishes papers in clinical

and / or research journals

and books

Professional Development and

Research continued

• Acts as primary supervisor for

Masters and PhD students

and staff

• Creates a context for staff to

be offered supervision in a

safe, respectful, non-judgmental

manner (as •outlined

in the camh Clinical

Supervision Handbook) as a

means of improving clinical

practice andclient outcomes

• Provides supervision of supervision

to clinical colleagues

• May provide teaching and / or

training to community partners

universities

Consultation and Education • Acts as a

• Provides supervision of new

preceptor/mentor/supervisor camh staff, undergraduates

for students and new staff to and students from community

support professional growth colleges

• Respects and solicits interdis- • May provide teaching and / or

ciplinary input into client and training to community part-

family care

ners and / or universities

140


PG121

A Pan American Health Organization /

World Health Organization Collaborating Centre 3542/03-2008

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