Clinical Supervision Handbook - CAMH Knowledge Exchange ...

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Clinical Supervision Handbook - CAMH Knowledge Exchange ...


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The Office of Nursing Practice and Professional Services<br />

(Centre for Addition and Mental Health) and<br />

the Faculty of Social Work (University of Toronto)











The Office of Nursing Practice and Professional Services<br />

(Centre for Addiction and Mental Health) and<br />

the Faculty of Social Work (University of Toronto):<br />

Kirstin Bindseil<br />

Marion Bogo<br />

Tim Godden<br />

Marilyn Herie<br />

Eva Ingber<br />

A Pan American Health Organization /<br />

World Health Organization Collaborating Centre<br />

Regine King Kathy Ryan<br />

Kate Kitchen Rani Srivastava<br />

Jane Paterson Lea Tufford<br />

Maria Reyes<br />

Cheryl Rolin-Gilman

ISBN: 978-0-88868-725-8 (PRINT)<br />

ISBN: 978-0-88868-726-5 (PDF)<br />

ISBN: 978-0-88868-727-2 (HTML)<br />

Product code PG121<br />

Printed in Canada<br />

Copyright © 2008 Centre for Addiction and Mental Health<br />

Any or all parts of this publication may be reproduced or copied with acknowledgement,<br />

without permission of the publisher. However, this publication may not be reproduced<br />

and distributed for a fee without the specific, written authorization of the publisher.<br />

This publication may be available in other formats. For information about<br />

alternative formats or other camh publications, or to place an order, please contact<br />

Sales and Distribution:<br />

Toll-free: 1-800 661-1111<br />

Toronto: 416 595-6059<br />

E-mail: publications@camh.net<br />

Website: www.camh.net<br />

This book was produced by the following camh staff:<br />

Editorial: Diana Ballon, Jacquelyn Waller-Vintar<br />

Design: Nancy Leung<br />

Print production: Christine Harris<br />

3542/03-2008 PG121<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong>

Contents<br />

v Contents<br />

ix Introduction<br />

ix Development of the <strong>Handbook</strong><br />

ix Perspectives on <strong>Clinical</strong> <strong>Supervision</strong><br />

x Literature Review<br />

x Framework for <strong>Clinical</strong> <strong>Supervision</strong><br />


1 Models of clinical supervision<br />

Social Work<br />

Nursing<br />

Common Elements<br />

Components of <strong>Clinical</strong> <strong>Supervision</strong> Models<br />

3 <strong>Clinical</strong> <strong>Supervision</strong> at camh<br />

Practice Environment<br />

Leadership<br />

<strong>Clinical</strong> <strong>Supervision</strong> Principles<br />

9 Components of <strong>Clinical</strong> <strong>Supervision</strong><br />

Roles<br />

Supervisory Activities<br />

11 Clinician Development<br />

12 Supervisor Development<br />

13 <strong>Clinical</strong> <strong>Supervision</strong>, <strong>Knowledge</strong> Translation and Evidence-Based Practice<br />

Incorporating Evidence-Based Practice into <strong>Clinical</strong> <strong>Supervision</strong><br />

17 Cultural Competence and <strong>Clinical</strong> <strong>Supervision</strong><br />

Cultural Competence<br />

Incorporating Cultural Competence into <strong>Clinical</strong> <strong>Supervision</strong> Practices<br />


23 Beginning <strong>Clinical</strong> <strong>Supervision</strong><br />

The <strong>Clinical</strong> <strong>Supervision</strong> Relationship and Contracting<br />

When <strong>Clinical</strong> <strong>Supervision</strong> is at the Request of the Manager<br />

Giving Feedback on Performance<br />

Learning Styles<br />

Learning Styles and <strong>Clinical</strong> <strong>Supervision</strong><br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

37 Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

Methods Of <strong>Clinical</strong> <strong>Supervision</strong><br />

Cultural Competence and Diversity<br />

Group <strong>Supervision</strong><br />

Individual <strong>Clinical</strong> <strong>Supervision</strong><br />

A Case Presentation Model for <strong>Clinical</strong> <strong>Supervision</strong><br />

Spontaneous <strong>Clinical</strong> <strong>Supervision</strong>: <strong>Clinical</strong> Supervisor as Lighthouse<br />


71 Interdisciplinary <strong>Clinical</strong> <strong>Supervision</strong><br />

Strengths of the <strong>Clinical</strong> Staff<br />

Staff Cultural Diversity and its Impact on <strong>Clinical</strong> <strong>Supervision</strong><br />

Context of Interdisciplinary <strong>Supervision</strong><br />

Interdisciplinary <strong>Supervision</strong> in Practice<br />

75 Nursing and <strong>Clinical</strong> <strong>Supervision</strong><br />

Reflective Practice<br />

Exploring Nurse’s Perceptions of <strong>Clinical</strong> <strong>Supervision</strong><br />

Practical Issues<br />

Preparation<br />

78 A Multi-Method Professional Development Approach in Daily Practice<br />

Integrated Care and Building Capacity in the Schizophrenia Program<br />

82 Ethical Considerations in <strong>Clinical</strong> <strong>Supervision</strong><br />

Standard of Care<br />

Ethical Considerations: An Example<br />

85 Evaluating <strong>Clinical</strong> <strong>Supervision</strong><br />

86 Core Competencies in <strong>Clinical</strong> <strong>Supervision</strong><br />

Benefits and Barriers to Effective <strong>Clinical</strong> <strong>Supervision</strong><br />

Evaluating Diversity Competence in <strong>Clinical</strong> <strong>Supervision</strong><br />

<strong>Clinical</strong> Supervisor Evaluation<br />

Documentation of <strong>Supervision</strong> In <strong>Clinical</strong> Settings<br />

103 APPENDIX 1<br />

103 Conceptualization of <strong>Clinical</strong> <strong>Supervision</strong>: A Review of the Literature<br />

Social Work<br />

Nursing<br />

Conclusion<br />


115 APPENDIX 2<br />

115 Evalautions For a <strong>Clinical</strong> <strong>Supervision</strong> Group<br />

PART A<br />

PART B<br />

117 APPENDIX 3<br />

117 <strong>Clinical</strong> <strong>Supervision</strong> Contract<br />

119 APPENDIX 4<br />

Contents<br />

119 Core <strong>Clinical</strong> Practice Competencies<br />

Levels of Practice<br />

Domains of Practice<br />


Introduction<br />

This handbook is the result of a group of advanced practice nurses and clinicians<br />

who function as clinical supervisors at the Centre for Addiction and Mental Health<br />

(camh) using their collective experiences to articulate a model of clinical supervision<br />

in this organization. It reflects the integration of clinical experience, practice<br />

wisdom and contributions from contemporary literature and research. The literature<br />

and research base informing this handbook is drawn primarily from the social work<br />

and nursing fields, with some references to psychology and organizational change. A<br />

comprehensive review and integration of the supervision literature from all allied<br />

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

from all disciplines will find relevant and practical tips and suggestions.<br />


We used a range of iterative and developmental activities to create the handbook.<br />

Initially there was considerable reflection and discussion about the nature of clinical<br />

supervision, the activities and processes that appeared to work, and the challenges<br />

faced. Individuals or small groups volunteered to develop topics further.<br />

Conceptual, practice and empirical literature about clinical supervision was reviewed<br />

from the perspectives of social work, nursing, psychology and other relevant sources.<br />

Further discussion of the material led to refinement of ideas and practices. The discussion<br />

also revealed confusion and tension about the definition of clinical supervision<br />

within an organization and about developing effective supervision practices.<br />


The development of the handbook was an inter-professional practice activity that<br />

brought together a team of experienced social workers and nurses. The members of<br />

the team share:<br />

• a commitment to client-centred care<br />

• a commitment to professional education and development<br />

• a common vision as employees of camh.<br />

Professions have their own distinct cultures, histories and practices. Terms such as<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

“supervision” therefore have different meanings for nurses than they do for social<br />

workers. As the working group explored clinical supervision, it became apparent<br />

that this concept and function is interrelated with ideas about:<br />

• power, authority, accountability and autonomy of individuals, managers and<br />

clinical supervisors<br />

• decision making in groups and teams<br />

• the perceived organizational conditions necessary for education and professional<br />

development.<br />


The review of the literature presents the diverse way these themes are conceptualized<br />

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

within professions there are different models of clinical supervision with varying<br />

emphasis on accountability, reflection, applying theory to practice, coaching and skill<br />

development, and integration of evidence-based practice. Through dialogue, it also<br />

became evident that individuals have different perspectives about the complex issues<br />

related to clinical supervision based on their own educational and work experiences.<br />

The handbook therefore merges concepts from diverse clinical disciplines, particularly<br />

nursing and social work, to develop an approach to clinical supervision that respects and<br />

builds on these traditions while providing guidance for the challenges of supervision<br />

and practice in mental health and addiction in contemporary society.<br />


The framework for supervision (see p. xx) represents current conceptualizations and<br />

can provide principles to guide the process of clinical supervision through its various<br />

stages. The goal is to enhance the knowledge of our clinical supervisory staff and<br />

delineate the standards of clinical supervision we provide at camh. Three interrelated<br />

functions of clinical supervision identified in both the nursing and social literature<br />

are discussed: administrative, educational and supportive (Kadushin, 1976; Kadushin<br />

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

along with a suggested evaluation method. Special issues in mental health and<br />

inter-professional settings are also examined.<br />

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

clinical supervision of staff is distinct from supervision of students. <strong>Clinical</strong> supervision<br />


Introduction<br />

can involve complicated organizational dynamics, hierarchies of administrative<br />

authority and multiple accountabilities (Tsui, 2005). Anyone who provides clinical<br />

supervision must be skilled in these practices. In <strong>Clinical</strong> <strong>Supervision</strong>, we discuss the<br />

ways in which a psychologically safe environment can be created so that complex<br />

clinical dilemmas can be brought forward. We also examine the clinical supervisor’s<br />

ability to provide clear and meaningful feedback and outline the parameters of clinical<br />

supervision.<br />

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

over time. We will continue to address the challenges outlined above through further<br />

consultation with clinical staff and colleagues in similar organizations. We welcome<br />

your comments and suggestions.<br />




Models of clinical supervision<br />

The definition of supervision differs across settings and professions.<br />


Social work literature reflects a long history of valuing clinical supervision as the<br />

crucial vehicle for professional development of the social worker (see Appendix 1,<br />

Conceptualization of clinical supervision: a review of the literature, p. 103). <strong>Supervision</strong><br />

in social work is essentially conceived as a method to ensure the organization’s<br />

mandate is achieved through enhancing the supervisee’s*ability to provide effective<br />

service. Through discussion of routine and complex clinical situations, clinicians are<br />

better equipped to meet client needs, and that, in turn, contributes to improved<br />

client outcomes.<br />


In the nursing literature there is less agreement on the definition of clinical supervision<br />

(see Appendix 1, Conceptualization of <strong>Clinical</strong> <strong>Supervision</strong>: A Review of the Literature,<br />

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

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

supervision challenging. It appears from this literature that clinical supervision<br />

has often been viewed as an authoritarian and hierarchical activity that arises in<br />

response to an error or indiscretion.<br />

This is beginning to change. Jones (2005) reviewed research literature on clinical<br />

supervision and credits Winstanley and White (2003) with the most comprehensive<br />


definition: “[clinical supervision focuses] upon the provision of empathetic support<br />

to improve therapeutic skills, the transmission of knowledge and the facilitation of<br />

reflective practice. The participants have an opportunity to evaluate, reflect, and develop<br />

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


A comparison of the social work and nursing literature on clinical supervision<br />

reveals common elements in the approaches offered by Kadushin’s model of three<br />

interrelated functions of social work supervision and one model in nursing, Proctor’s<br />

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

work agree that clinical supervision should be differentiated from, on one hand, an<br />

exclusive focus on line management, and, on the other, a quasi-therapeutic approach,<br />

although elements of each may be present at times in the process of supervision.<br />


Administrative/normative (managerial)<br />

Kadushin uses the term administrative supervision to describe selecting and orienting<br />

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

serving as socializing agent; and advocating and buffering within the organization.<br />

Proctor uses the terms normative or managerial to describe a function that promotes<br />

and complies with organizational policies.<br />

Educational/formative<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Both professions’ models have an educational component. For Kadushin, education<br />

encompasses activities that develop the professional capacity of supervisees, including<br />

teaching knowledge and skills, and developing self-awareness (Barker, 1995;<br />

Munson, 2002) through, for example, teaching, case consultation, facilitating learning<br />

and growth. For Proctor, educational supervision addresses skill development<br />

for evidence-based nursing practice.<br />


Supportive/restorative<br />

<strong>Clinical</strong> <strong>Supervision</strong> at camh<br />

Kadushin’s third component is supportive supervision. He sees this component as<br />

helping workers to handle job-related stress by providing appropriate praise and<br />

encouragement, normalizing work-related reactions, affirming strengths, and sharing<br />

responsibility for difficult decisions. Proctor’s third component, restorative (also<br />

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

practitioner to understand and manage the emotional stress of nursing practice.<br />

Each of these components is seen as influencing each other and as producing more<br />

effective services for clients when operating in concert.<br />

<strong>Clinical</strong> <strong>Supervision</strong> at camh<br />

At camh, we are committed to upholding the highest standards of clinical care and<br />

practice and to supporting the best clinical practice, professional education and professional<br />

development for our staff. We strive to be a workplace where people excel<br />

in a culture that embraces diversity and encourages teamwork, quality improvement,<br />

safety and respect. We have a rich inter-professional environment at camh with<br />

approximately 1,500 clinical staff representing 16 professional disciplines. It is essential<br />

that these clinicians be supported in the work they do and that they receive the<br />

organizational support required for ongoing professional growth and development.<br />

<strong>Clinical</strong> supervision has been identified as one of the most important factors in<br />

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

believe that it is important to establish standards for clinical supervision<br />

practice. We also realize the vital role that clinical supervision plays in supporting<br />

clinicians in adapting to change. Initiatives such as Concurrent Disorders Capacity<br />

Building, <strong>Clinical</strong> Cultural Competence, Building a Culture of Safety, Family<br />

Centred Care, and Implementing a Recovery Framework are examples of broadbased<br />

initiatives at camh that are supported by clinicians. Front-line clinicians are<br />

vital to the successful implementation of these initiatives and when operational<br />

challenges are encountered, clinical supervision plays a crucial support role.<br />



The practice environment must include multiple perspectives and interests.<br />

Individual clinicians are accountable to clients, colleagues, organizations and regulatory<br />

bodies. Organizations must ensure standards and delivery of high quality care.<br />

External stakeholders may influence practice with advice on models of practice that<br />

should be emphasized. Funders link resources to outcomes, and consumer and family<br />

groups are now active partners in program planning and service delivery. As an<br />

organization, we must acknowledge and accept differing—and at times opposing—<br />

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

differ from the practice advice from a regulatory body. It is our task to create a practice<br />

environment that allows for the expression of divergent opinions with the goal of<br />

resolving issues. <strong>Clinical</strong> practice dilemmas and errors are a fact of life; it is the<br />

response that counts. A culture of blame, over-regulation and punitive responses<br />

will deter disclosure. Opportunities to identify the underlying conditions that led<br />

to those clinical dilemmas and errors will be lost unless processes for review and<br />

reflection are established to allow disclosure and discussion of difficult issues. Thus<br />

clinical supervision has a dual focus: clinician development; and improved care and<br />

enhanced health for our clients.<br />

At camh, the desired practice environment includes:<br />

• clinicians practicing ongoing critical self-appraisal<br />

• an openness to the opinions and input of the client, and the work of the clinical<br />

supervisor<br />

• honest communication<br />

• clear and regular documentation<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

• clinical practice that actively explores, examines and contributes to the evidencebase<br />

for care and support<br />

• an acknowledgement of the complexities of clinical practice<br />

• empowerment of clients, families and communities<br />

• active and ongoing dialogue among employees at all levels.<br />

The process of clinical supervision is integral to the realization of these goals.<br />



The clinical discipline chiefs, the advanced practice group and the clinical leadership<br />

in the program areas have primary responsibility for development of professional<br />

knowledge and skills. The discipline chiefs and the advanced practice group are in<br />

many ways more similar than different in the roles and functions they perform in<br />

the organization. The roles of both groups comprise five interrelated domains:<br />

• practice<br />

• consultation<br />

• education<br />

• research and scholarship<br />

• leadership.<br />

Perhaps the greatest difference between the two groups is that the discipline chiefs<br />

are senior clinicians who lead the entire professional discipline across the organization<br />

and are responsible for ensuring that professional practice standards are<br />

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

senior clinicians, work directly in the clinical programs and supervise clinicians<br />

from various disciplines. Members of the discipline chiefs, program clinical leadership<br />

and the advanced practice groups can all have a role in the clinical supervision<br />

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

of clinical supervision in order that job achievement be recognized and acknowledged.<br />


<strong>Clinical</strong> supervision at camh is guided by the following interrelated principles:<br />

• organization context and its crucial impact on the nature and quality of clinical<br />

supervision<br />

• improved client outcomes<br />

• accountability<br />

<strong>Clinical</strong> <strong>Supervision</strong> at camh<br />

• advancement of clinicians’ specialized knowledge, skill and use of evidence-based<br />

practice<br />

• learning and professional development.<br />

These principles support the organization’s goals of improved client-centred<br />


care; enhanced health and client safety; and support, growth and retention of the<br />

best professional staff.<br />

Organizational context<br />

<strong>Clinical</strong> supervision occurs within the organizational context and will be customized<br />

in response to the unique characteristics of a particular clinical program area.<br />

Organizations that value and promote clinical supervision as both an educational<br />

process for clinicians and as a way to enhance accountability achieve greater employee<br />

satisfaction and improved client outcomes.<br />

Two overarching organizational themes characterize camh: a unionized environment<br />

and clientele divided between inpatient and outpatient services. The hierarchical<br />

environment of a unionized setting places the responsibility for clinical supervision<br />

on those at the managerial level. All clinicians require high-quality clinical supervision<br />

to meet their challenges and need for ongoing support. As an organization,<br />

it is important that we find ways to provide clinical supervision to staff that work<br />

shifts in the inpatient and residential areas at times when managers and clinical<br />

supervisors may not be readily available to provide consultation.<br />

When two or more hospitals merge to form a new organization, the organizational<br />

culture often differs from that of its founding organizations. This may affect the<br />

availability, perception and experience of clinical supervision. It takes time to develop<br />

a shared perspective on the nature and process of clinical supervision. Any organization<br />

comprises many departments, disciplines and individuals with a range of working<br />

styles that contribute to its overall rhythm and achievements. <strong>Clinical</strong> supervision<br />

requirements will vary with the unique program, culture, team members and learning<br />

styles of its participants and so must be tailored accordingly. For example, when<br />

camh was formed, there wasn’t a consistent practice of clinical supervision across<br />

the entire organization. Although it was agreed that clinical supervision is integral to<br />

clinical practice, it was necessary to redefine clinical supervision in this new culture.<br />

Improved client outcomes<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

One of the aims of clinical supervision is the improvement of client outcomes. Given<br />

the breadth of service at camh outcomes are not the same for all clients but fluctuate<br />

to accommodate client needs and challenges. Increasingly, we experience greater<br />

complexity in the client populations we treat.<br />


Accountability<br />

The supervisory relationship entails accountability within a supportive and educational<br />

framework. By virtue of their role in the organization, clinical supervisors,<br />

along with the staff they supervise, have accountability for client outcomes. Also, the<br />

clinical supervisor is responsible for monitoring the clinical performance of staff.<br />

The accountability demands on health care organizations are generally steep and the<br />

clinical supervisor needs to account for client and worker outcomes. It is challenging<br />

for the supervisor to balance the two functions of support and accountability. People<br />

engaged in clinical supervision need to discuss this duality from the outset. It also<br />

challenges more traditional notions of clinical supervision, where a clinician would<br />

be assured of almost complete confidentiality in processing cases with the clinical<br />

supervisor.<br />

Specialized knowledge, skill and use<br />

of evidence-based practice<br />

The following summarizes the generic competency required of all camh clinical staff<br />

regardless of professional discipline:<br />

• clinician-client relationship<br />

• family and social support<br />

• professional autonomy and accountability<br />

• professional development and research<br />

• assessment and monitoring<br />

• interviewing, formulation and documentation<br />

• treatment planning<br />

• therapeutic interventions<br />

• anticipating and responding to rapidly changing clinical situations<br />

• evaluation of care<br />

• teaching, coaching and empowering<br />

• teamwork, collaboration and partnerships<br />

• ethical, organizational and legal accountabilities<br />

• consultation and education<br />

<strong>Clinical</strong> <strong>Supervision</strong> at camh<br />


For a description of the requirements for each of these domains, see Appendix 4,<br />

p. 119.<br />

As well as generic competencies, all clinicians are expected to have specialized<br />

knowledge and clinical skills associated with the clinician’s program.<br />

Professional development<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Professional development within one’s discipline flows from a commitment to lifelong<br />

learning: clinical supervision is one method for achieving this goal. Regulated<br />

health professionals are members of regulatory bodies with annual educational<br />

requirements and standards of practice and ethical conduct. Unregulated clinicians<br />

who are members of professional associations often must meet educational objectives<br />

to qualify for, and maintain, membership. <strong>Clinical</strong> supervision can help clinicians<br />

stay abreast of developments in their field.<br />

Educational and clinical supervisory opportunities may be provided in ones’ place<br />

of employment. Many professionals participate in external educational activities such<br />

as courses, workshops or private consultation. In organizationally offered clinical<br />

supervision, clinicians demonstrate their commitment to ongoing learning and show<br />

accountability to the process through their willingness to learn, their interest in<br />

developing their clinical skills and being open to receiving support and being challenged.<br />

Through the formation of a partnership for learning, clinical supervisors<br />

and clinicians agree to journey together toward both the development of clinicians<br />

as learners and as members of their colleges.<br />


Components of <strong>Clinical</strong> <strong>Supervision</strong><br />

ROLES<br />

Clinician<br />

Components of <strong>Clinical</strong> <strong>Supervision</strong><br />

In clinical supervision, clinicians can achieve a higher level of expertise in their<br />

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

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

develop a more accurate self-appraisal and, through discussion, to draw the links<br />

between theory and practice.<br />

<strong>Clinical</strong> supervisors and clinicians work together to develop and maintain productive,<br />

goal-oriented supervision. They negotiate the framework in which clinical supervision<br />

is carried out, including establishing the frequency of meetings, avoiding outside<br />

interference and being prompt. Clinicians define their own learning goals. The goals<br />

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

from supervision and from activities clinicians undertake beyond the supervisory<br />

session. Clinicians prepare for clinical supervision by having an agenda and information<br />

pertinent to the case or to clinical dilemmas. Information can include case notes,<br />

segments of tapes, a care plan and case questions. Case material should represent<br />

challenges and difficulties as well as successes. By choosing to discuss cases where they<br />

have encountered difficulties, clinicians demonstrate their willingness to take risks<br />

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

reflection on practice, and receiving both challenging and supportive feedback. The<br />

clinician records the supervisor’s recommendations and the actions or outcomes he<br />

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

and in the interdisciplinary plan of inpatients.<br />

Clinicians are active participants in clinical supervision and give feedback to the<br />

supervisor so they can jointly evaluate the process in relation to the verbal or written<br />

supervision contract. Contracting at regular intervals allows the clinician to discuss<br />

learning goals, and the clinical supervision process, and to adjust the contract as<br />

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

with clients. Self-evaluation is imperative and allows clinicians to determine when<br />

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

role with clients, such as in leading a group.<br />


Learning is not relegated to the confines of the supervision session. The clinician<br />

and clinical supervisor, working together, must negotiate and agree on the expectations<br />

for learning between sessions. Activities may include reading, viewing videos<br />

and writing process recordings or detailed notes of sessions.<br />

<strong>Clinical</strong> supervisor<br />

<strong>Clinical</strong> supervisors demonstrate substantive or content knowledge in multiple<br />

domains through discussion of clinical issues, examination of organizational development<br />

and inter-professional practice. The ability to work with the content of<br />

multiple domains engenders confidence in supervisory skills. <strong>Clinical</strong> supervisors’<br />

credibility, based on formal education and depth of experience, is an important<br />

contributor to the supervisor-clinician relationship. Another factor is the availability<br />

of clinical supervisors for both scheduled and unscheduled supervision, since concerns<br />

related to clients also arise beyond the usual hours of the working day. Good<br />

clinical supervisors recognize and value diverse perspectives. They also acknowledge<br />

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

work environment.<br />

Shared responsibility<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

The supervisor and the clinician share responsibility for creating a safe environment<br />

for clinical supervision. Safe environments are characterized by respect, openness,<br />

support, trust and the provision of non-judgmental feedback. The establishment<br />

of a safe environment allows creativity to flourish when dealing with challenging<br />

situations and expands the possibilities of service delivery.<br />

Power and authority<br />

The hierarchical aspect of the supervisor-clinician relationship can lead to conflict,<br />

stress and tension. Effective clinical supervisors don’t ignore the inevitable power<br />

dynamics. Instead they model a parallel process of journeying together. <strong>Supervision</strong><br />

experts note as crucial the ability to exercise supervisory responsibility in a respectful,<br />

fair and objective manner and to purposefully avoid the abuse of power (Centre<br />

for Substance Abuse Treatment, 2007).<br />



Clinician Development<br />

Clinicians come to clinical supervision with a diverse array of learning styles, such<br />

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

teaching to match the learning styles of clinicians is a critical supervisory skill<br />

(see Learning styles, p. 33). Observation, discussion, feedback, role play, coaching,<br />

demonstrating and questioning are examples of supervisory activities. Supervisors<br />

need to master each of these so they can customize learning activities to meet the<br />

needs of all the clinicians with whom they are working.<br />

Conceptual frameworks that link theory to practice that’s relevant to camh clients<br />

help clinicians’ work to progress in an intentional and planned manner. Reflection<br />

encourages and provides the opportunity for clinicians to consider their experiences<br />

in practice, explore feelings invoked through working with clients, and understand<br />

the meanings they give to interactions. This process allows clinicians to arrive at<br />

more mindful and deliberate subsequent interventions. Critical self-reflection and<br />

self-inquiry helps clinicians recognize their strength and growth areas.<br />

Clinician Development<br />

Clinicians pass through stages in their careers. In the early stages of their careers, or<br />

when they join a new organization, clinicians may benefit from increased support,<br />

education and clinical supervision as they orient themselves to the organizational<br />

environment and clientele. Later career professionals may require less clinical supervision<br />

and more focused case consultation.<br />

Most professionals are educated in their specific disciplines, and while in training<br />

may have little opportunity to collaborate with other disciplines. However, in health<br />

care organizations, they are expected to participate in teamwork and collaborative<br />

practice. There is an increasing number of inter-professional education initiatives<br />

that recognize the knowledge base required to practice collaboratively. The curricula<br />

of the health care disciplines are evolving so that students will have the opportunity<br />

for curriculum and practicum experiences in collaborative practice.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

The optimization of holistic clinical care first requires clinicians to be well grounded<br />

in their own professional discipline. It is a challenge for a junior clinician to maintain<br />

this professional identity and assert the unique perspective of the discipline within<br />

the interdisciplinary team. Without the opportunity for regular clinical supervision<br />

and reflection on their unique roles in teams, junior clinicians can risk aligning<br />

themselves with the power base on a team, thus silencing the unique perspective of<br />

their discipline. The clinical supervisor therefore must consider the career stage of the<br />

clinician in choosing pertinent material and issues for supervisory sessions.<br />

Supervisor Development<br />

<strong>Clinical</strong> supervisors, similar to clinicians, engage in professional development in<br />

their various roles. Reflection on their practice as clinicians and as supervisors allows<br />

them the opportunity to examine themselves from cognitive, affective and behavioural<br />

angles. By acknowledging strength areas and challenging inherent assumptions<br />

and ineffective patterns, clinical supervisors deepen their level of service offered to<br />

both clients and clinicians and are able to seek their own supervision as required.<br />

Professional development may also result in further expertise in a clinical issue or<br />

exploration of a new area. <strong>Clinical</strong> supervisors are in an excellent position to provide<br />

leadership with respect to evidence-based practice through staying abreast of the<br />

most current literature and introducing new concepts, practices and guidelines in<br />

their supervisory meetings with clinicians. Continuous learning refreshes clinical<br />

processes, allows clinical supervisors to remain current and promotes a similar<br />

commitment on the part of clinicians.<br />

The processes of transference and countertransference are two of the inevitable<br />

by-products of working in helping professions. Effective clinical supervisors understand<br />

the dynamics of these two processes both between client and clinician and<br />

between clinician and clinical supervisor. <strong>Clinical</strong> supervisors facilitate clinicians’<br />

understanding of how these dynamics impact on clinical work. At the same time,<br />

clinical supervisors reflect on their personal transference and countertransference<br />

issues to promote their development.<br />


<strong>Clinical</strong> <strong>Supervision</strong>, <strong>Knowledge</strong> Translation and Evidence-Based Practice<br />

<strong>Clinical</strong> <strong>Supervision</strong>,<br />

<strong>Knowledge</strong> Translation<br />

and Evidence-Based Practice<br />

Organizations of all sizes are increasingly concerned that clinical practice be based<br />

on research where possible. The rise of “best practice” documents and guidelines<br />

attests to the urgency of bridging the gap between research and practice and reflects<br />

the reality that most clinicians do not read—let alone incorporate—scientific findings<br />

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

management have all identified “knowledge translation” as a major challenge.<br />

<strong>Knowledge</strong> translation has been defined by the Canadian Institutes of Health Research<br />

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

within a complex system of relationships among researchers and users.” There is a<br />

growing body of literature on the topic of knowledge translation relevant to health<br />

care. The notion that clinical decisions should be made based on evidence-based<br />

practices and systematic review has become widely accepted (Zwarenstein & Reeves,<br />

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

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

immediate or consistent basis because of the varying characteristics of adopters<br />

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

up first by innovators and early adopters—the “champions” of practice innovations—<br />

followed by the early majority, the late majority and the small group of late adopters<br />

or “laggards.” In recognition of the challenges of transferring and adapting research<br />

findings to clinical practice, attention has been focused on understanding factors<br />

affecting the transfer of knowledge.<br />

Reviews of knowledge transfer literature have suggested that the failure of collaboration<br />

and communication between health care professionals has a profoundly negative<br />

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

To address this issue, it is important to design a clinical supervision process that<br />

accommodates the needs of the many professions and disciplines in the health care<br />

system, and to develop good inter-professional collaboration.<br />

One of the most common strategies in enhancing or incorporating evidence-based<br />

practice has been through clinically focused, continuing education workshops.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

However, research has shown that clinical practice is minimally influenced by training<br />

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

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

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

there is some evidence that clinical training combined with ongoing feedback and<br />

coaching (such as that provided through supervision) can yield significant improvement<br />

(Miller et al., 2006).<br />

<strong>Clinical</strong> supervision is, therefore, critical for promoting the use of evidence-based<br />

models and tools, as well as an effective means of disseminating these approaches.<br />

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

material and workshops cannot substitute for proper clinical training, feedback and<br />

supervision in helping providers learn more effective ebt [Evidence-Based Treatments]”<br />

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

adhere to—evidence-based treatment models, knowledge translation should be a<br />

major focus of clinical supervisors’ work.<br />



Ongoing feedback and coaching are critical in helping clinicians to implement<br />

evidence-based practice applications and treatment protocols. <strong>Clinical</strong> supervision<br />

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

are prerequisites:<br />

• <strong>Clinical</strong> supervisors and clinicians understand and are committed to evidencebased<br />

practice approaches.<br />

• The clinical supervisor has expertise in the evidence-based methods in which<br />

clinicians are practising.<br />

• There are opportunities for observation and practice of clinicians’ clinical<br />

interactions during supervision sessions.<br />

• <strong>Clinical</strong> supervisors provide corrective feedback that is experienced by clinicians<br />

as constructive, relevant and credible.<br />


<strong>Clinical</strong> <strong>Supervision</strong>, <strong>Knowledge</strong> Translation and Evidence-Based Practice<br />

Commitment to evidence-based practice<br />

The implementation of evidence-based approaches is not without controversy<br />

among human service practitioners, and has been criticized on the grounds that<br />

it privileges empiricism over other dimensions and sources of wisdom, such as<br />

qualitative research, practice wisdom, consumer perspectives, cultural considerations<br />

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

acknowledge the ways in which our understanding of evidence-based practice has<br />

evolved. For example, Petr and Walter discuss how, in the social work field, the<br />

rise of empirically based practice in the late 1980s emphasized clinical practice<br />

based primarily on scientific expertise. By the mid-1990s this notion broadened<br />

to consider the appropriateness of research applications to individual situations,<br />

ethical issues, and client values and expectations. Current conceptualizations refer<br />

to “evidence-based practice wisdom,” with an appreciation of multiple sources<br />

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

supervisors to discuss clinicians’ understanding of evidence-based practice, and<br />

to explore how clinicians apply advances in scientific knowledge and integrate<br />

these with other knowledge sources.<br />

Supervisor expertise<br />

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

advanced proficiency in evidence-based treatment protocols. <strong>Supervision</strong> requires<br />

a deep, critical understanding of the theoretical, research and practice dimensions<br />

of these treatment approaches, as well as an ability to deconstruct these approaches<br />

into concrete, practical applications. As an analogy, not all outstanding athletes are<br />

successful coaches: applying skills is different from teaching and supporting skill<br />

development in others. There is a large literature related to adult education and<br />

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

a summary of adult learning theory and practice that is concise yet comprehensive.<br />

Opportunities for observation and practice<br />

<strong>Clinical</strong> supervisors need to resist the temptation to use clinical supervision time<br />

primarily for discussing cases and dispensing advice. Learning by doing, or active<br />

learning (based on the learning theory known as constructivism), has become the<br />

hallmark of current approaches to teaching and learning (Tight, 1996). Examples<br />

of incorporating active learning into supervision might include:<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

• role-playing a challenging case example with the clinician<br />

• live observation and feedback of a clinical consultation<br />

• practising a discrete skill (such as complex reflections in motivational interventions)<br />

with clinicians<br />

• playing a video recording of a session with frequent pauses for critical, reflective<br />

commentary by the clinician and/or clinical supervisor/group.<br />

• In all of the above examples, clinical skills are examined in the context of the<br />

evidence-based treatment application being applied or demonstrated.<br />

Psychological safety and constructive feedback<br />

Demonstrating skills in front of clinical supervisors and peers is often experienced<br />

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

respect, positive regard and non-judgmental acceptance. Fostering a positive learning<br />

climate can be better accomplished when clinical supervisors model their willingness<br />

to take risks and are transparent about the areas they need to further develop. For<br />

example, the clinical supervisor could first demonstrate practice activities before<br />

asking clinicians to do so. In addition, feedback is generally experienced as more<br />

constructive and salient when it is neutral, concrete and references the skills or<br />

philosophy underlying the clinical approach.<br />

In summary, advancing skills development in evidence-based practice approaches<br />

means that clinical supervisors must:<br />

• facilitate a shared understanding and appreciation of the meaning of evidencebased<br />

practice<br />

• be proficient in supporting clinicians to learn evidence-based approaches and<br />

apply these approaches to practice<br />

• apply and critique concrete strategies and tools in a safe and supportive learning<br />

context.<br />


Cultural Competence and <strong>Clinical</strong> <strong>Supervision</strong><br />

Cultural Competence and<br />

<strong>Clinical</strong> <strong>Supervision</strong><br />

The diverse, multicultural makeup of our society means we must carefully consider<br />

issues of race, culture and other dimensions of diversity. Developing cultural competence<br />

is now “a recognized requirement for achieving professional standards in therapy<br />

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

competence in mental health practice has been described as a professional as well as<br />

a moral and ethical imperative. As noted by Sue and colleagues:<br />

White culture is such a dominant norm that it acts as an invisible veil<br />

that prevents people from seeing counseling as a potentially biased<br />

system.…What is needed is for counselors to become culturally aware,<br />

to act on the basis of a critical analysis and understanding of their<br />

own conditioning, the conditioning of their clients, and the sociopolitical<br />

system of which they are both a part. Without such awareness,<br />

the counselor who works with a culturally different [sic] client may<br />

be engaging in cultural oppression using unethical and harmful<br />

practices. (Sue et al., 1992, p.72-73)<br />


The term cultural competence was first defined by mental health researchers over a<br />

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

a system, agency, or amongst professionals and enables that system, agency or those<br />

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

In this definition “culture” refers to integrated patterns of human behaviour that<br />

include the language, thoughts, communications, actions, customs, beliefs and values<br />

of racial, ethnic, religious or social groups. Culture should not be conceptualized<br />

narrowly in terms of only race, ethnicity, and country of origin; instead, culture must<br />

be defined broadly as inclusive of various diversity dimensions including, but not<br />

limited to, age, gender, gender identity, sexual orientation and socio-economic status.<br />

“Competence” implies having the capacity to function effectively as an individual<br />

and an organization within the context of the cultural beliefs, behaviours and needs<br />


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

cultural competence is differentiated from cultural sensitivity and awareness by a<br />

need for action and altering practices to effectively interact with different cultural<br />

groups. (cdc National Prevention Information Network, n.d). Cultural competence<br />

in clinical care encompasses an understanding of the other’s worldview, a critical<br />

understanding of the dynamics of power and social location in our society, and the<br />

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

There are many frameworks and models of cultural competence across the various<br />

disciplines. A critical examination of the literature, however, reveals remarkable similarity<br />

in the requisite competencies. The differences are more in the area of emphasis<br />

(Haarmans, 2004). There is general agreement that clinical cultural competence<br />

comprises three domains as described by Sue and colleagues:<br />

• awareness of attitudes, values and biases (affective domain)<br />

• knowledge (cognitive domain)<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

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

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

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

domain refers to the dynamics inherent in a clinician-client relationship with similar<br />

and different cultural values, racial identity attitudes and issues of power, control,<br />

and oppression (Haarmans, 2004). For a more comprehensive discussion of clinical<br />

cultural competence, see Haarmans.<br />

Development of cultural competence is generally recognized as a process that evolves<br />

with time, experience and deliberate attention. As such, cultural competence is often<br />

described on a continuum, with one end reflecting little recognition of the need for<br />

incorporating culture into care, and the other end where cultural knowledge and<br />

insight lead to innovative practices and positive outcomes for the client, the clinician<br />

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

Although much has been written on the need to develop cultural awareness, skills<br />

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

little information is available on how to imbed and develop cultural competence<br />

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

operationalized definition for clinical cultural competence (ccc) and a corresponding<br />

lack of validated, comprehensive measures needed for training and research are<br />

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




Within the supervision process, the need for cultural competence is evident at two<br />

distinct, but inter-related levels. These are:<br />

• developing a clinician’s capacity in cultural competence<br />

• addressing the dynamics of culture and difference within the superviseesupervisor<br />

relationship.<br />

The supervision process is an effective vehicle for assessing a clinician’s multicultural<br />

competence and further developing cultural awareness, knowledge and skills. It has been<br />

described as an effective process for examining the conscious and the unconscious<br />

pathologizing of clients and therapists (Tummala-Narra, 2004). Raising cultural<br />

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

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

strategies that move supervisees from knowing that cultural differences exist<br />

(cultural sensitivity) to knowing how to work with individuals from diverse groups<br />

(cultural competence) (Cashwell et al., 1997). To support this journey, intellectual<br />

understanding needs to be augmented by actual examples from practice. An understanding<br />

of how our own gender, race, ethnicity, religion, socioeconomic class,<br />

generation and geographical region shape our sense of self can result in increased<br />

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

Power dynamics<br />

Cultural Competence and <strong>Clinical</strong> <strong>Supervision</strong><br />

The challenges of cultural dynamics are not limited to work with clients; they apply<br />

equally to the process of supervision itself and the supervisor-supervisee relationship.<br />

Research examining the experiences of supervisees of colour highlights the<br />

perception that the supervisors’ clinical approaches are often “rooted in a limited,<br />

dominant culture perspective, despite their good intentions to attend to issues of<br />

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

racially or culturally relevant material, either because of a lack of knowledge, or due<br />

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

knowing” can feel threatened by the client’s or the supervisee’s cultural knowledge.<br />

However, such supervisory encounters perpetuate racial enactments and can be<br />

silencing for the therapist and the client (Tummala-Narra, 2004).<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Another emotion that can impede the supervision encounter is shame. Lybarger<br />

(2001) describes three progressively deeper levels of shame: embarrassment, humiliation<br />

and mortification. Embarrassment is associated with feeling self-conscious, ill<br />

at ease, disconcerted or flustered; humiliation occurs when there is a perceived loss<br />

of pride or dignity and mortification occurs when humiliation is deep and is associated<br />

with feelings of helplessness, hopelessness and despair. Tummala-Nala suggests<br />

that the lack of supervisor initiative to explore issues of diversity can contribute to<br />

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

reactions such as avoidance and withdrawal on the part of the supervisee. Although<br />

it is important to explore diversity issues in the supervisory encounter, it needs to be<br />

done with an awareness that racial discourses continue to be highly emotional and<br />

can lead to feelings of vulnerability. For these reasons it is critical to determine the<br />

extent to which the supervisory relationship is a safe space for exploration of such<br />

issues (Tummala-Nala, 2004).<br />

Supervisory competencies and<br />

strategies for addressing diversity<br />

While there is no one approach to developing cultural competence for clinical supervision,<br />

there are a variety of methods that can assist supervisors. It is critical that<br />

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

identity development. “Culturally skilled counselors are constantly seeking to understand<br />

themselves as racial and cultural beings and are actively seeking a nonracist identity”<br />

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

is often dependent upon clinical supervisors who consistently model behaviour that<br />

is reflective and acknowledges the power held in a supervisory relationship.<br />

<strong>Clinical</strong> supervisors are in the unique position to be mentors, teachers, supporters<br />

and evaluators. This unique relationship of supervisor-supervisee is markedly different<br />

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

competent supervisors are able to understand and put into perspective the worldviews<br />

of their diverse supervisees and clients and reflect the experience to the staff.<br />

During supervision they are able to create a positive environment where there is<br />

an opportunity for staff members to address and discuss issues that may be related<br />

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

competent supervisors have the ability to work across cultures and work with clinical<br />

staff to do the same.<br />


Supervisors can influence clinicians by helping them investigate ways to maintain<br />

language competency while communicating or when trying to understand the<br />

diverse communication styles of their clients. In supervision, they can share valid<br />

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

Supervisors can also use a variety of strategies to address issues of diversity, race and<br />

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

to new and unknown information are foundational requisites for these strategies<br />

(Tummala-Narra, 2004). Some approaches to develop cultural competence include<br />

role play, interpersonal process recall, first person feedback and metaphor (for a<br />

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

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

• increasing cultural knowledge<br />

Cultural Competence and <strong>Clinical</strong> <strong>Supervision</strong><br />

• initiating the discussion of race and culture<br />

• attending to transferential responses<br />

• engaging in multicultural education.<br />

Although no individual is expected to have detailed knowledge about every cultural<br />

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

knowledge and range of communication skills in order to model these to their supervisees<br />

(Garret et al., 2001). This generic cultural knowledge includes knowledge of:<br />

• institutional barriers that prevent some clients from using mental health services<br />

• history, experience and consequences of oppression, prejudice, discrimination,<br />

racism and structural inequalities<br />

• the heterogeneity that exists within and across cultural groups and the need to<br />

avoid overgeneralization and negative stereotyping (Haarmans, 2004).<br />

While it may be important at times for the supervisor to ask the supervisee about<br />

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

such inquiries should not be considered sufficient to serve as a knowledge base that<br />

guides supervision or psychotherapeutic interventions (Tummala-Narra, 2004).<br />

Supervisors and clinicians need to make a commitment to acquire such knowledge<br />

as part of their ongoing learning, and use the supervisee or client to validate the<br />

issues pertinent to them as members of particular groups.<br />

Initiating discussion of cultural and diversity issues is another recommended strategy.<br />

Such initiation by the supervisor recognizes the power dynamics of the relationship<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

and challenges the traditional notion of neutrality and normalizing the complexity<br />

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

create a safe environment where such discussions can occur openly and without the<br />

experience of shame. Such discussions can also highlight communication barriers that<br />

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

Encounters between clients, supervisees and supervisors from different cultures<br />

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

These reactions may be based on individual characteristics as well as characteristics<br />

associated with particular racial or cultural groups. In reflecting on transferential<br />

responses it is important to critically reflect on one’s own assumptions and traditional<br />

views. It is also important to consider the ways in which racial and cultural<br />

identity shapes social and psychic realities and interpretations. Such a stance will<br />

minimize avoidance and treatment of cultural issues as “extraneous” or “exotic”<br />

(Tummala-Narra, 2004).<br />

Lastly, it is important for supervisors to engage in ongoing education on multicultural<br />

perspectives as they relate to psychopathology and therapy. Research indicates a<br />

strong link between self-rated competence and the number of diverse clients seen by<br />

the therapist, suggesting that treating diverse client groups is an important training<br />

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

and engage in discussions on race, culture and mental health. Such exploration<br />

and reflection will assist the supervisor and the supervisee in understanding the<br />

complexities of culture and its relationship to mental health and mental illness.<br />

In summary, the rapidly changing demographics of clients require increased attention<br />

to culture and the supervisory relationship. The tools for ensuring supervisees’ cultural<br />

competence are within reach and require a commitment from each one of us as<br />

clinicians and as supervisors. Cultural competence is a critical skill for both individual<br />

and group supervision and can be developed through a variety of experiential<br />

learning approaches. Integral to this process is reflection on such issues as power<br />

dynamics, divergence of world views and stereotyping.<br />




Beginning <strong>Clinical</strong> <strong>Supervision</strong><br />



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

about clinical supervision, what the program leadership hopes to obtain from clinical<br />

supervision and what the clinician knows about and expects from the clinical supervision<br />

process. This is an opportunity to develop relationships and clarify expectations.<br />

In the process of contracting, you can begin to provide a foundation for the clinical<br />

supervisory relationship. Although this is useful to do at the beginning, it is important<br />

to remember that relationship clarification and contracting will likely occur throughout<br />

the clinical supervisory process.<br />

Shulman (1993) identifies four main areas of contracting as you develop relationships<br />

in the beginning phase of a clinical supervisory situation:<br />

• share the sense of purpose<br />

• describe the clinical supervisor’s role<br />

• elicit feedback from the clinician on his or her perceptions of clinical supervision<br />

• discuss mutual obligations and expectations related to the clinical supervisor’s<br />

authority.<br />

Sense of purpose<br />

The clinical supervisor should discuss the purpose and expectations of clinical<br />

supervision with the clinician. A shared purpose offers clarity about the clinical<br />

supervisory process for the program staff, the clinical supervisor and clinician. You<br />

should discuss several definitions of clinical supervision with the program and<br />


clinician to learn how the program staff will use the clinical supervision process in<br />

day-to-day work.<br />

<strong>Clinical</strong> supervisor’s role<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

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

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

functions of clinical supervision and support of staff. There is a growing recognition<br />

that these roles are distinct from that of the manager in that the manager is the individual<br />

responsible for the administrative functions of the program. These leadership<br />

roles of clinical supervisor and manager have many areas of shared responsibility<br />

such as program development and the facilitation of team processes. The challenge<br />

for people in these roles is to navigate the boundary between performance management<br />

and clinical supervision. The challenge is to deliver supervision that provides<br />

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

time making sure that administrative managers feel adequately informed about matters<br />

under their purview.<br />

Elicit feedback from the clinician<br />

A discussion about perceptions, beliefs and attitudes about clinical supervision can<br />

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

last clinical supervisor or the clinical supervision model can help to clarify present<br />

expectations and allow constructive feedback. This is an opportunity to begin to<br />

develop trust and understanding with the clinician.<br />

Discuss mutual obligations and expectations related to<br />

authority<br />

Although clinical supervisors may be uncomfortable with discussing authority, they<br />

should discuss the balance between their supervisory and managerial roles with<br />

every one they supervise as soon as possible in the supervision relationship. Many<br />

clinicians are concerned about when information will be shared with management<br />

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

the manager attend some of the sessions? Will management receive reports about<br />

the clinical supervision sessions? It is important to be clear about expectations,<br />


Beginning <strong>Clinical</strong> <strong>Supervision</strong><br />

procedures and roles so that clinicians can develop a clear understanding of the<br />

parameters of the clinical supervision process.<br />

Dealing with suboptimal standards of practice<br />

What are the clinical supervisors’ obligations once they have become aware of<br />

suboptimal standards of practice?<br />

To answer this question, we need to consider at least two scenarios:<br />

• when issues arise spontaneously in supervision<br />

• when issues are generated from performance management and supervision.<br />

When issues arise spontaneously in supervision<br />

A well-functioning supervision relationship can resolve many challenges. A good<br />

general rule is that a practice issue identified in supervision sessions can remain<br />

within the confines of supervision as long as the client’s care has not been seriously<br />

compromised and the supervision process is yielding results. If either of these<br />

conditions were not met, the clinical supervisor would need to consult with the<br />

manager. For example:<br />

• When clients complain about inappropriate staff behaviour, the manager should<br />

be informed and directly involved in the plan to follow up on the complaint,<br />

since the event could lead to disciplinary action. The clinical supervisor’s role<br />

can be to follow up with the areas of concern highlighted by the complaint and<br />

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

the inappropriate behaviour.<br />

• If the clinician and the clinical supervisor don’t agree that the clinician’s behaviour<br />

is a concern, then the clinical supervisor should inform the manager and all could<br />

decide together how to proceed.<br />

• If the clinical supervisor learns at any time that a clinician has broken the code<br />

of conduct of the organization or has violated the code of ethics as established by<br />

the clinician’s regulatory body, then the manager must be informed.<br />

Even when the clinical supervisor takes an issue outside the confines of clinical<br />

supervision, the consultation with the manager can be considered a resource to help<br />

to resolve a problem that may not require performance management and discipline.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

When issues are generated from performance management processes<br />

Any clinical supervision task generated by the performance management system<br />

should include the following:<br />

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

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

meet expectations<br />

• a precise plan outlining what kind of documentation will be required from the<br />

clinician to monitor performance<br />

• the maximum length of time available for achieving the task at hand<br />

• details on how the clinical supervisor will report progress and to whom these<br />

reports will be given<br />

• an understanding of the consequences if there is a recurrence of the suboptimal<br />

practice.<br />

Attending to the above details will assist clinical supervisors and staff in marking the<br />

end of a specific, performance-management supervision task, and the restoration of<br />

a “business as usual” clinical supervision relationship.<br />

Discuss the goals of clinical supervision<br />

It is helpful to talk about the atmosphere clinicians believe they need to develop<br />

their clinical skills. This is likely to entail discussions about the importance of creating<br />

a safe place for clinicians to share information, thoughts and feelings related to<br />

their work. <strong>Clinical</strong> supervision is different from therapy in that clinical supervision<br />

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

process of developing trust and safety in the relationship is introduced in the initial<br />

meeting and is reinforced through the experiences of interacting with the clinical<br />

supervisor in the day-to-day work.<br />

It is also useful to discuss with the clinician the types of approaches available in the<br />

program for professional development and growth. For example, in some programs<br />

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

others, audio- or videotapes are available. Some programs present opportunities<br />

for learning through co-therapy and review, while others will rely primarily on<br />

case presentation and consultation. This is further discussed in the next section.<br />

Contracts can be general or specific with regards to learning goals, activities and<br />


Beginning <strong>Clinical</strong> <strong>Supervision</strong><br />

time frames. Contracts can be verbal or written. The following case example<br />

illustrates the process of establishing a verbal contract.<br />



Regina, a new clinician who recently graduated from school,<br />

starts a permanent position as an addiction therapist in the residential<br />

program. As part of her orientation, Regina is asked to<br />

meet with the clinical supervisor (an advanced practice clinician)<br />

and manager to discuss roles and expectations, the role of clinical<br />

supervision in this setting, the process of group clinical supervision<br />

and the scheduling of individual clinical supervision. The<br />

clinician is also offered a few definitions of clinical supervision<br />

that are used in this setting.<br />

Because she will report to both the clinical supervisor and manager,<br />

Regina is given some guidelines about areas appropriate for<br />

discussion with the clinical supervisor and other areas to be<br />

discussed with the manager. The APC role focuses on practicerelated<br />

issues through education and support while the manager’s<br />

role is more administrative, as well as being supportive.<br />

In building the relationship with the clinical supervisor, Regina is<br />

asked questions about past clinical supervision as a student as<br />

well as any questions or concerns she has about working with the<br />

clinical supervisor in this setting. From this discussion, the clinical<br />

supervisor learns that Regina experienced her student supervisor<br />

as holding grudges and often felt punished for earlier mistakes in<br />

her placement. This information leads the clinical supervisor<br />

to be sensitive when giving feedback, to acknowledge that the<br />

clinician cannot always make perfect choices and to articulate her<br />

hope that the clinician approach her if she were unsure of her<br />

work in the early days, as a way to obtain help and support.<br />

The clinical supervisor also discusses circumstances that are<br />

somewhat unique to the program. Unlike other settings, there is<br />

opportunity for the clinician to connect with the clinical supervisor<br />

around daily clinical issues. Also, there are some situations such<br />


as discharging a client, where a consultation from a representative<br />

from management is required. The clinical supervisor would<br />

share, upon request from the manager, the level of participation<br />

negotiated for clinical supervision, consistent with the initial<br />

discussion of roles and responsibilities.<br />

Finally, the clinician is asked to reflect on her work as a student<br />

and identify some goals she has for this staff position. Regina is<br />

also asked if there are any resources or courses that might<br />

enhance her clinical practice.<br />



When clinicians are told that they are required to attend clinical supervision, a variety<br />

of feelings may arise for both clinician and clinical supervisor. The clinical supervisor<br />

may believe that he or she should have offered supervision earlier or may wonder if<br />

he or she could have provided a more supportive environment so the clinician could<br />

have come to supervision sooner. From the perspective of the clinician, there may be<br />

positive feelings because the clinician has struggled with a clinical situation and now<br />

feels supported by the added attention or help. Alternatively, clinicians can feel very<br />

stressed as they may feel targeted as having done something wrong. Clinicians may<br />

feel that they have been betrayed by sharing their struggle with another member of<br />

the team, and telling the truth about a difficult situation or be embarrassed because<br />

other clinicians told management about unsafe clinical practices. In circumstances<br />

when a clinician is returning to the workplace after disciplinary action, there can be<br />

feelings of anger and embarrassment.<br />

Clinicians may be told to attend clinical supervision because they need to:<br />

• comply with the mandatory regulating body<br />

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

• attend clinical supervision as part of a disciplinary action or as part of a return<br />

to work procedure<br />

• integrate evidence-based practice into their work<br />

• focus on client-centred care<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />


• manage burnout and workload<br />

• concentrate on a specific deficiency in clinical competency that<br />

has been identified.<br />

Clear contracting is crucial under these circumstances as often the perception of trust,<br />

between team members and management, has weakened and some type of a report is<br />

expected. Some examples of questions to consider for the purpose of clarity are:<br />

• Will the requested need for clinical supervision address the concern entirely or<br />

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

of the role of the supervisor)?<br />

• What is the time frame expected for the clinician to accomplish the goal of<br />

clinical supervision?<br />

• What details in the report does the manager expect?<br />

• What will happen if the clinician does not attend or comply?<br />

• What are indicators of compliance?<br />

Beginning <strong>Clinical</strong> <strong>Supervision</strong><br />

• What will happen if the clinical supervisor does not write a positive report?<br />

It is helpful to clarify the clinical supervisor’s role to ensure the best outcome of<br />

clinical supervision. Once the role has been determined, the manager, clinician and<br />

clinical supervisor should meet to review the expectations and document what is<br />

being requested.<br />

Similar to the processes described earlier regarding contracting in general and establishing<br />

the working relationship with the clinician, it can be helpful to obtain feedback<br />

about how the clinician feels about the structure of the supervision process.<br />

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

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

with the clinician about his or her clinical goals can help the clinician see the value<br />

of clinical supervision, improve his or her professional skills and fulfil the needs of<br />

the program.<br />



Jacob, a social worker on a psychiatric inpatient unit, continued<br />

to see the parents of a client after the client was transferred to<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

another clinical team. Jacob did not believe the new social worker<br />

understood the family’s distress or perspective because he<br />

thought he could better identify with their Eastern European background.<br />

When management learned that Jacob was seeing this<br />

family, it was decided that he had overstepped his boundaries<br />

and should have referred the family to the new clinical team. He<br />

was disciplined and asked by his manager to attend clinical<br />

supervision.<br />

Jacob came to clinical supervision not really knowing what to<br />

expect. He recognized that he had overstepped a boundary; however,<br />

he was upset with being disciplined and thought his manager<br />

had treated him unfairly. He also did not want talk to anyone<br />

about the situation because he did not believe that he would be<br />

supported if he sought out clinical supervision. A contract was<br />

developed to reflect the expectation to discuss boundary crossing<br />

and ways that Jacob could approach management for more support<br />

if needed. Also, Jacob was asked if there were any other areas<br />

of skill that he would like to develop in clinical supervision. He<br />

mentioned that given the increased workload in documentation,<br />

he would like some guidance around documentation.<br />

A meeting was set with Jacob, the clinical supervisor and the<br />

manager to discuss the goals of clinical supervision (boundaries,<br />

asking for more support and documentation). It was negotiated<br />

that the individual sessions occur once a week for one month as<br />

this appeared to be adequate time to discuss these topics. After<br />

one month, the clinical supervisor—with Jacob’s input—would<br />

complete a report of Jacob’s progress. If more time were<br />

required, this would need to be renegotiated.<br />

In clinical supervision, Jacob discussed his current clinical cases,<br />

the clinical supervisor brought thoughtful articles and information<br />

for Jacob to consider and documentation was reviewed. After<br />

one month, Jacob felt more confident in his work and better able<br />

to ask for assistance in the future.<br />


Beginning <strong>Clinical</strong> <strong>Supervision</strong><br />


The clinical supervisor and clinician should regularly review the clinical supervision<br />

process and recontract when necessary. Later in the handbook, we will discuss ways<br />

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

meant to provide some ideas about offering feedback to clinicians.<br />

Clinicians will usually have many opportunities to receive feedback. Although<br />

clinicians will learn from a variety of sources, the clinical supervisor has an explicit<br />

responsibility to assist in the clinicians’ development and growth.<br />

The task of providing feedback may feel quite strange especially if the clinical supervisor<br />

has recently been promoted from the role of clinician. A discussion with peer<br />

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

reasons why a clinical supervisor will have the capacity to provide unique and valuable<br />

feedback. The clinical supervisor:<br />

• can often compare strategies used by a variety of supervisees and offer<br />

opportunities to develop consistency among clinicians<br />

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

goals and help to match practice to the organizational context<br />

• is not working directly with the client and therefore has the opportunity to<br />

review issues with more distance and perhaps clarity<br />

• is simply able to provide alternate perspectives that have not been considered.<br />

Feedback should highlight strengths as well as identify opportunities for learning. It<br />

is important to take any opportunity to offer positive feedback. If a clinician shows<br />

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

to highlight the work. By offering this strength-based approach to feedback<br />

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

the overall context of a positive work environment that values the clinician’s strengths<br />

and need for continuous learning.<br />

When offering feedback that may be difficult for the clinician to hear, the clinical<br />

supervisor will want to provide an optimal learning environment. The best option is<br />

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

find a time that the clinician can meet without interruption in a confidential space.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

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

the feedback is about a particular situation and will allow an opportunity for the<br />

clinician to respond and perhaps offer more information. If the issue is not linked<br />

to a specific incident or situation, the clinical supervisor might need to provide<br />

concrete examples to support the feedback. Providing the clinician with an example<br />

illustrates the precise nature of the concern and also gives the clinician a chance<br />

to clarify any misunderstandings. The clinical supervisor may also wish to provide<br />

this feedback in writing.<br />

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

to give clinicians feedback that may seem minor, early feedback can<br />

give clinicians the opportunity to absorb the information, respond faster and use<br />

other resources in addition to clinical supervision to assist with making changes<br />

to their practice.<br />


Janet is a clinical nurse in an outpatient addiction treatment service.<br />

At her bi-weekly clinical supervision, Janet described working with<br />

a client who was “mandated” by the child protection authority<br />

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

through the motions” to get her child back. The client had stopped<br />

using crack cocaine; however, she reportedly used marijuana<br />

occasionally.<br />

The marijuana use and the fact that the client was not interested<br />

in making any psychological changes concerned Janet and were<br />

the reasons she was asking for clinical supervision. The fact that<br />

the client was intending to end treatment in two more sessions<br />

also caused Janet to worry that she had not done all that she<br />

should to help effect change.<br />

The clinical supervisor first wanted to point out how the sessions<br />

with the client appeared successful in relation to her goals<br />

of treatment, part of which was to see the client stop using<br />

crack. Janet could agree that the previous sessions may have<br />

been helpful but was unsure about whether she had sufficiently<br />

addressed her client’s cannabis use. They discussed the importance<br />

of the therapeutic relationship apart from the client’s<br />


cannabis use—which Janet felt was quite positive—as well as the<br />

importance of the client’s efforts and strengths outside of the<br />

therapeutic relationship.<br />

The clinical supervisor then explored feelings around the client<br />

“going through the motions” and discussed if this interfered with<br />

Janet’s lack of feelings of success about this client. The clinical<br />

supervisor then asked about whether cas would object to<br />

occasional marijuana use, given that her doctor had prescribed<br />

her marijuana, and concluded this would likely not be a great<br />

concern to cas.<br />

Finally the clinical supervisor gave her some feedback about her<br />

approach with the client. She told Janet that she could use the last<br />

two sessions to tell the client what she really thought about the<br />

marijuana use, or she could work toward cultivating a<br />

relationship with the client so if she ever wanted to address the<br />

marijuana use or her feelings around using crack cocaine, this<br />

would be a safe place for the client to return regardless of whether<br />

she was still involved with cas.<br />

Janet was able to see that her approach to the client had been<br />

focused more on substance use (very common in a substance<br />

use service) and less on maintaining a relationship with the client<br />

to foster further growth and development if the client wished to<br />

seek out further treatment.<br />


Beginning <strong>Clinical</strong> <strong>Supervision</strong><br />

A learning style is “a predominant and preferred approach which characterizes an<br />

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

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

differ from those of their colleagues or the clinical supervisor. Learning styles can<br />

vary on a variety of dimensions.<br />



structured unstructured<br />

method description intuition<br />

concrete abstract<br />

active reflective<br />

individual group learning<br />

visual auditory<br />

self-directed clinical supervisor-directed<br />

There are a variety of models of learning styles available for learners to consider.<br />

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

people can learn on two axes: a perceptual continuum from concrete to abstract<br />

and a processing continuum from active to passive. From this work, he presents<br />

four distinct learning styles:<br />

• accommodator<br />

• diverger<br />

• converger<br />

• assimilator.<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Accommodator style (feel and do): preference for concrete<br />

experience and active experimentation<br />

Accommodators are “hands on” and rely on intuition rather than logic. They prefer<br />

a practical and experiential approach. Accommodators may prefer to rely on instinct<br />

instead of providing a logical response. This is a useful approach when the situation<br />

requires action and initiative. Accommodators work well on teams to complete tasks.<br />

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

Learning activities include shadowing, doing the clinical work and talking about it in<br />

clinical supervision or having the clinical supervisor observe the work.<br />


Beginning <strong>Clinical</strong> <strong>Supervision</strong><br />

Diverger style (feel and watch): combination of concrete<br />

experience and reflective observation<br />

Divergers are often able to look at a situation from different perspectives. Such<br />

learners are sensitive, and prefer to watch rather than do, tending to gather information<br />

and use imagination to solve problems. They prefer to work with groups, to<br />

listen with an open mind and to receive personal feedback.<br />

Learning activities include shadowing, role modelling and reviewing teaching tapes.<br />

Converger style (think and do): abstract conceptualization<br />

and active experimentation<br />

Convergers are problem solvers. They prefer to focus on technical tasks, and are less<br />

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

ideas and theories. They are good researchers and often have technological abilities.<br />

They like to experiment with new ideas, to simulate and to work with practical<br />

applications.<br />

Learning activities include reading various theoretical perspectives, getting feedback<br />

from clinical supervisor reviewing their clinical work, developing treatment plans<br />

and role plays.<br />

Assimilator style (think and watch): combination of abstract<br />

conceptualization and active experimentation<br />

Assimilators are logical and concise. They tend to focus on ideas and concepts. They<br />

look for a clear explanation rather than a practical response. They excel at understanding<br />

wide-ranging, often theoretical information and organizing it in a clear and<br />

logical format. They are less focused on people and more interested in ideas and<br />

abstract concepts. Like the converger, the assimilator likes a scientific approach.<br />

They prefer to read, attend lectures, explore analytical models and have time to think<br />

things through.<br />

Learning activities include reading various theoretical perspectives, viewing learning<br />

tapes, developing treatment plans and watching other clinicians.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />


While most people may see aspects of themselves reflected in each style, each discrete<br />

style can be regarded as a particular type. These types provide ways to help<br />

both clinician and clinical supervisor identify their own preferred learning styles.<br />

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

and supervisor have different learning styles, each can expand their repertoire and<br />

adapt to how information is presented and absorbed by the other, producing rich,<br />

new ways of extracting optimal learning from various situations. Supervisors can<br />

assist clinicians to use familiar and new learning styles to try new and challenging<br />

practices, acknowledge discomfort and set goals that overcome barriers.<br />

The supervisor can also share his or her own preferred learning style and then discuss<br />

learning options outside of the clinical supervisor’s preferred learning style. This helps<br />

to stimulate discussions about how the clinician can further enhance his or her clinical<br />

practice and allow for a variety of approaches to be used depending on the clinical<br />

situation. In this way, the clinical supervisor works with the clinician to construct<br />

the best learning environment.<br />


In developing a new psychotherapy group, a clinician had done a<br />

great deal of preparation by reading books on the topic, speaking<br />

to another therapist who leads this type of group and observing a<br />

few sessions of this type of group. However, the clinician still felt<br />

there was more to learn. The clinical supervisor thought there<br />

was little more to offer the clinician to assist in preparation, and<br />

therefore decided to talk about learning styles. The clinician<br />

acknowledged that he was more reflective and enjoyed conceptualizing<br />

the group from descriptions that emerged from the literature.<br />

The clinical supervisor acknowledged that he learned best<br />

with active participation and would be the type of learner who<br />

would start the group and intuitively learn more as he went along.<br />

This allowed both to pause and reflect on what else was needed<br />

for the clinician to feel able to start the group. It was decided that<br />

the clinician was likely ready to start the group in two weeks and<br />

both would assess progress as the group went forward.<br />


As this example illustrates, the clinician and clinical supervisor<br />

were able to address the learning needs of the clinician by first<br />

discussing their own unique learning styles. These discussions<br />

can further assist in developing new ways to plan, conduct and<br />

evaluate the learning. Often this will come about as part of a discussion<br />

when some type of mismatch is occurring. This discussion<br />

can lead to a positive and productive discussion of clinical<br />

practice.<br />

Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />


There are a variety of methods used to provide clinical supervision. Some include<br />

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

rely on review of clinicians’ work by examining audio, video or written records or by<br />

verbal case presentations. This section discusses four of these methods:<br />

• demonstration / reflecting mirrors<br />

• co-therapy<br />

• role-playing<br />

• reviewing audio and / or videotapes.<br />

Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

These methods address the various learning styles described by Kolb: accommodator,<br />

diverger, converger and assimilator.<br />

Demonstration / reflecting mirrors<br />

Demonstration<br />

Typically, the clinical supervisor and clinician meet in advance and discuss a particular<br />

struggle that the clinician is having or identify a particular set of skills that the<br />

clinician needs to learn. Then the clinical supervisor meets with the clinician and his<br />

or her client and takes the lead in the interview with the client. The clinical supervisor<br />

debriefs with the clinician afterward, asking the clinician what he or she noticed and<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

how the clinical supervisor’s responses were similar and different to those of the<br />

clinician. The clinician is present during the interview between the client and the<br />

clinical supervisor and the debriefing is an opportunity for the clinician to compare<br />

what the clinical supervisor did with what the clinician would have done if he or<br />

she were conducting the interview.<br />

Reflecting Mirrors<br />

In the reflecting mirrors technique, the clinical supervisor is in a room with the<br />

client. The clinician sits outside of the room, looking through a reflecting mirror.<br />

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

process, debriefing. The supervisor and clinician roles can be reversed, with the<br />

clinical supervisor observing the clinician interview the client.<br />


Both the Keeping Safe and Enhancing Women’s Well Being<br />

groups are co-facilitated with a member of staff or a student as a<br />

way of modelling how to run the group. The clinical supervisor<br />

shows them how to:<br />

• help the group establish norms<br />

• review the content of the handouts in a way that respects the<br />

needs that the clients bring forward in the sessions<br />

• manage conflict within the sessions<br />

• ensure there is a balanced opportunity for clients who tend to be<br />

silent and for those who are more outspoken to share the floor<br />

• elicit opportunities for clients to hear the commonality of experience<br />

and learn that they have something to offer one another<br />

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

verbally underlining meaningful interventions that she or he<br />

makes and returning to them if they get lost in the session.<br />


For the Enhancing Women’s Well Being Group, the clinical supervisor<br />

facilitates the sessions with a graduate student in a room<br />

that has a one-way mirror. While this method is used for student<br />

learning, it can also be used for staff development. Other students<br />

and staff are invited to observe. They are given a sheet of<br />

paper with specific questions to reflect on as they watch the<br />


group. The clinical supervisor uses these questions to shape the<br />

learning experience for all supervisees. The questions are:<br />

1. What is different and similar about this group and other groups<br />

you have observed or participated in?<br />

2. How is gender playing itself out in this group? What themes do<br />

you notice?<br />

3. How are diversity issues experienced in this group (i.e., class,<br />

culture, sexuality)?<br />

4. What questions do you have about the choices that the co-facilitators<br />

made in terms of facilitation during this session?<br />

General comments and debriefing<br />

A range of questions can be used depending on what the supervisor intends observers<br />

to learn from the observation experience. For example, MacKenzie (1990) developed<br />

a Group Climate Questionnaire that asks observers (and group members and facilitators)<br />

to rate the group as a whole along various dimensions that break into three<br />

subscales: engaged (a positive working environment), conflict (a negative atmosphere<br />

with anger and distrust) and avoiding (of personal responsibility for group work).<br />

Using a tool like this increases observers’ awareness of the interaction between members<br />

and between members and facilitators. The tool reinforces the differences between<br />

working with clients individually and within a group, highlighting areas to explore<br />

further in future sessions when gaps are noticed.<br />

After the group, the co-facilitators debrief with the observers, discussing their responses<br />

to the questions as well as processing their observations of group member interactions<br />

and what they observed the co-facilitators do. This provides an excellent learning<br />

opportunity for all involved since there are often a variety of strategies that can be<br />

used at any given time.<br />

Co-therapy<br />

Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

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

the clinician and the clinical supervisor. This allows the clinician to observe the<br />

strategies used by his or her clinical supervisor, and it enables the clinical supervisor<br />

to observe the clinician’s interventions and to provide immediate feedback.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />


The clinical supervisor meets with the staff member before he or<br />

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

history of the group, its goals, co-facilitators’ roles, what the clinician<br />

can expect to occur, and to explore what the clinician feels comfortable<br />

doing. The clinical supervisor continually evaluates the<br />

clinician’s involvement and interventions over time and monitors<br />

the clinician’s desire to take more risks within the group.<br />

Prior to each session, the clinical supervisor and staff member<br />

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

the Enhancing Women’s Well Being Group, which is a 14-session,<br />

closed outpatient group, there is greater opportunity for continuity<br />

since the same people facilitate for the whole cycle. The cofacilitators<br />

can review previous sessions and decide what needs<br />

to be followed up on and what roles they might each take for the<br />

particular meeting.<br />

After the session, the clinical supervisor takes some time to<br />

debrief. During this time, the co-facilitators reflect on what<br />

occurred with respect to the clients—themes, participation level,<br />

critical issues—and what they noticed each other do and the<br />

response from clients. This provides them with the opportunity to<br />

notice how their skills are developing and the impact their strategies<br />

are having on the group. The clinical supervisor shares what<br />

she was thinking during the group that influenced what she said<br />

or did not say. After the clinical supervisor has modelled this<br />

process, the staff member does the same, which expands the<br />

opportunity to discuss what he or she did and did not do and the<br />

reasons underlying interventions. The co-facilitators discuss what<br />

their follow-up will be in the next session and the cycle continues.<br />

The clinical supervisor invites her co-facilitator to risk trying a<br />

strategy that the clinician had thought about, but had not done.<br />

Within the Keeping Safe Group, staff members learn that even<br />

though it theoretically makes sense for the program’s clients to<br />

have safety plans, the process goes beyond ensuring that clients<br />

have completed these plans. Staff members need to be open to<br />


eflecting on the barriers that clients experience, speaking about<br />

what prevents them from being able to follow through on using<br />

their plans, and helping clients process their resistance as<br />

opposed to getting into a power struggle with them.<br />

Role playing<br />

After the clinician describes a challenge he or she is encountering with a client, the<br />

clinical supervisor can suggest a role play where the clinician and clinical supervisor<br />

act out the situation where the clinician had trouble. For example, if the clinician<br />

plays the role of the client, the clinical supervisor can show the clinician other ways<br />

of responding to what the client is saying. The roles can be reversed, with the supervisor<br />

taking on the client role. This variation requires that the supervisor has enough<br />

information about the client’s responses to be able to respond meaningfully. The<br />

supervisor can see how the clinician responded to the situation in question and then<br />

give feedback.<br />

Reviewing taped sessions<br />

Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

The clinician is asked to either audio- or videotape the session or sessions with a<br />

client. The clinician must ensure that the client understands that this is being done<br />

to help the clinician provide optimal care. After this has been explained, the clinician<br />

must obtain written consent from the client. The clinician reviews the tape and<br />

marks the segment that he or she would like to discuss with his or her supervisor.<br />

The clinician plays this segment during the session and the clinician and clinical<br />

supervisor discuss their observations. The clinician may first be asked to talk about<br />

what he or she was thinking and feeling at the time and how these thoughts and<br />

feelings contributed to what he or she did or did not say.<br />


Influence of privilege and oppression<br />

in the therapeutic relationship<br />

Skilled clinicians possess knowledge and understanding about how oppression, racism,<br />

discrimination and stereotyping affect them both personally as well as in their work.<br />

They are knowledgeable about how sociopolitical influences impinge on the lives of<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

people who are marginalized because of race, culture, gender, sexuality, age, language,<br />

religion and abilities. Without this awareness, clinicians can respond to their clients<br />

with a range of feelings such as anger, defensiveness, sadness and powerlessness, and<br />

miss opportunities to explore how these life experiences have contributed to the<br />

client’s mental health and addictions. The Wheel of Intersecting Axes of Privilege,<br />

Domination and Oppression (see Figure 1, p. 43) is a tool that can be used to help<br />

clinicians raise their awareness in this area as they plot themselves along the various<br />

axes and consider where their clients are located as well. This helps to identify where<br />

there might be tensions in the clinician-client relationship due to meanings that<br />

either person may attribute to specific incidents within the relationship based on life<br />

experience. This tool also facilitates the exploration of contextual factors that are<br />

important to consider as the clinician assists the client in his or her recovery. For<br />

example, a client is not open about her sexual identity as a lesbian. Keeping this<br />

hidden influences her relationships with others resulting in shame, guilt, depression<br />

and anxiety. She drinks to cope. The clinician assumes the client is heterosexual<br />

and thus misses a key issue that has contributed to the client’s mental health.<br />

Using the tool<br />

Introduce the tool to clinicians by explaining the rationale for its use, as described<br />

above. Then ask the clinicians to take some time and put an “X” on each axis at the<br />

point that represents where they see themselves. If this exercise is done in group clinical<br />

supervision, tell the clinicians that they are not required to share the details with<br />

the group. After they have completed the exercise, ask them what they noticed—did<br />

anything in particular jump out for them? Many people are surprised at the number<br />

of axes and how they experience greater privilege in some areas as opposed to others.<br />

Next, ask the clinicians to think about the clients they currently see and to place<br />

them on all of the axes based on what they know about them. Then ask how they<br />

think their experiences and those of their clients might influence their relationship<br />

with one another. For example, the clinician is a Caucasian, well-educated woman,<br />

middle class, married, with two children. Her client is a single, black woman, making<br />

enough money to pay her bills, raising three young children on her own. She did not<br />

complete high school. She has been involved in the sex trade as her main source of<br />

income to support herself and her children. She uses alcohol and marijuana to cope<br />

with her feelings, and the experience of having been sexually abused in childhood<br />

by her father. Based on the clinician’s experience and biases, she or he may not raise<br />

questions about how racism and childhood sexual abuse may have contributed to<br />

dropping out of school, having limited employment opportunities due to discrimination<br />

and an overall poor sense of self.<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />



Source: From A., Diller, B. Houston, B., Morgan, K.P. and Ayim, M. (1996).The Gender Question in Education: Theory,<br />

Pedagogy, and Politics. Boulder, CO: Westview Press. Reprinted with permission.<br />


Questions for reflection<br />

In addition to using the diagram, clinicians are asked to consider the following<br />

“Questions for Reflection” to further explore what influences their perceptions of the<br />

client in addition to experiences of privilege and oppression. Through this exercise,<br />

the clinical supervisor helps the clinician to break through stereotypes; acknowledge<br />

his or her beliefs and values; and understand how stereotypes, beliefs and values can<br />

be barriers to understanding the client’s experience. The exercise may raise new<br />

issues for discussion with the client (e.g., asking about experiences of discrimination,<br />

and what it is like for them having a therapist who is from a different culture, race).<br />

These questions were developed by Donna Akman, PhD, CPsych, and Cheryl<br />

Rolin-Gilman, rn, mn, cpmhn(c), Women’s Program, Centre for Addiction<br />

and Mental Health.<br />

A Thoughts/feelings about client/session:<br />

• What am I puzzled by with this client/situation?<br />

• What occurred in the interaction with this client?<br />

• What were my thoughts and feelings?<br />

B Personal/social location:<br />

• What is my personal/social location with respect to this client,—i.e., along continuum<br />

of privilege to oppression—(race, gender, language, sexuality, race, ability, education,<br />

age, fertility, European in origin vs. non-European, Aboriginal, attractiveness,<br />

colour, etc.)?<br />

C Observations/reflections about session:<br />

• What did I learn from observing/reflecting on my experience? What are the<br />

essential aspects that I am aware of?<br />

• What are alternative methods of action that I can take with my understanding?<br />

D From the questions below, choose one that you would like to discuss:<br />

• What factors influenced my response in this situation?<br />

• What was I trying to achieve?<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

• How were others feeling? How did I know this?<br />


• Does this situation connect with previous experiences I have had?<br />

• How do I feel about this experience?<br />

• What were my hopes for the outcome of this incident?<br />

• How were my hopes related to my own expectations?<br />

• What are the sources of my knowledge in my life and work?<br />

• What are the sources for my ideas and values?<br />

• To what extent were social norms or expectations (including organizational)<br />

operating in this incident?<br />

Adapted from: Johns, C. (2000). Becoming a Reflective Practitioner: A Reflective and Holistic Approach to <strong>Clinical</strong><br />

Nursing Practice Development and <strong>Clinical</strong> <strong>Supervision</strong>. Oxford, England: Blackwell Science.<br />

Tate, S. (2004). Using critical reflection as a teaching tool. In S. Tate & M. Sills (Eds.), The development of critical<br />

reflection in the health professions. Occasional paper (4). Learning and Teaching Support Network (LTSN) Centre<br />

for Health Sciences and Practice, (pp. 8–17).<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

Although the literature tends to focus on individual clinical supervision, given time<br />

and budget constraints, clinicians will probably be more exposed to group supervision.<br />

The following is adapted from a series of studies on group supervision conducted<br />

by Bogo, Globerman and Sussman (2004a).<br />

In group supervision, a group of clinicians meet on a regular basis with one supervisor.<br />

Group supervision allows clinicians to present examples of their practice and, through<br />

discussion, learn from exposure to a wide range of ideas and perspectives offered by their<br />

supervisor and peers. Through peer interaction, clinicians can develop a more accurate<br />

self-appraisal of their ability and learn about group process and group dynamics.<br />

Groups can function in different ways. Examples include rotating case presentations<br />

or focusing on particular topics and their relationship to the therapeutic relationship<br />

(e.g., working with clients with a trauma history, stage-oriented trauma treatment).<br />

Novice clinicians have the opportunity to learn from experts. Experts develop by<br />

demonstrating their ability to self-reflect. They do this by bringing their experiences<br />

of their clients to the group, and by sharing their thought processes as they discuss<br />

the questions they have asked themselves in order to better understand the choices<br />

they made in response to their client’s behaviour. They talk about the connection<br />

they make between theory and similar situations they have encountered with other<br />


clients, illustrating where they have been able to generalize an approach and where<br />

they have had to make modifications.<br />

Purposes of group supervision<br />

Group supervision provides opportunities for clinicians to learn skills in peer supervision<br />

and to experience support from colleagues who may be struggling with similar<br />

feelings around caring for a challenging client. Group supervision can also contribute<br />

to team cohesiveness and provide a rich experience for exploring several different<br />

perspectives. Group supervision may be more feasible than individual clinical supervision,<br />

particularly on a busy inpatient unit where taking time away to meet oneto-one<br />

may not always be practical. It may also be a desirable method of supervision<br />

with reduced resources.<br />

Successful group supervision<br />

Group supervision is most successful when the supervisor is available and supportive,<br />

and regular scheduled sessions are offered that are flexible in duration and protected<br />

from interruptions. Supervisors can show support by demonstrating respect for<br />

the supervisees, by not minimizing their opinions, and by allowing them to make<br />

mistakes. Successful group supervision is highly dependent on the supervisor’s ability<br />

to assist group members to process group dynamics, especially when they interfere<br />

with sharing practice and learning issues.<br />

Leadership style<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

<strong>Clinical</strong> supervisors need to provide staff with an orientation to group supervision.<br />

Staff members must feel safe (i.e., not feel embarrassed, shamed or sense that others<br />

are competing with them to be the “best clinician”) and understand what is expected<br />

of them. They should also be asked what they expect from the group and the supervisor.<br />

The clinical supervisor should ensure that both content and process issues are<br />

addressed. <strong>Clinical</strong> supervisors model expected behaviour of a group member and<br />

provide feedback in a way that focuses on the clinician’s strengths rather than his or her<br />

mistakes. They intervene when group members’ behaviours do not support the norms<br />

of risk-taking and providing constructive feedback. For example, in the case of a<br />

clinician who does not discuss difficulties that she or he has working with clients,<br />

tending instead to focus on questioning others about their practice, an intervention<br />


y the clinical supervisor might be to ask the clinician if he or she ever experiences<br />

what other group members are discussing (e.g., similar feelings in response to client<br />

behaviours) and how the clinician dealt with these feelings when they arose. <strong>Clinical</strong><br />

supervisors provide equal opportunity for each clinician to participate, rather than<br />

favouring one clinician over others.<br />

Benefits of group supervision<br />

Group supervision:<br />

• allows for learning from other clinicians’ interactions with clients; from the<br />

diverse backgrounds and experiences of both clinicians and clients; and from<br />

different perspectives on issues<br />

• provides opportunities for reflection and discussion with others—hearing how<br />

others reflect on their work, including the kinds of questions they ask<br />

• examines the relationship between theory and practice<br />

• helps clinicians learn about group dynamics<br />

• allows clinicians to practice new behaviours<br />

• demonstrates the universality of concerns, such as, “I am not the only one who<br />

thinks they do not know what they are doing” or “I am not the only one who is<br />

feeling hopeless about this client situation”<br />

• helps clinicians develop more accurate self-appraisals.<br />

Obstacles to productive group supervision<br />

Learning is compromised when some or all of the following occur.<br />

Content issues<br />

Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

• There is too much focus on administrative issues such as scheduling<br />

and procedures.<br />

• Not enough time is spent reviewing clinical issues.<br />

• Too much time is spent sharing information rather than on reflection and dialogue.<br />

Process issues<br />

• Group supervision turns into individual supervision with an audience (i.e., clinicians<br />

place themselves in a vulnerable position by disclosing their struggles while the<br />


est of the team says nothing and the supervisor only focuses on the presenting<br />

clinician).<br />

• The supervisor does not process feedback from others (i.e., no one ties feedback<br />

together or links to others’ experiences).<br />

• Clinicians feel overly criticized.<br />

• Clinicians feel others are not taking risks.<br />

• A lack of open communication impedes group cohesion.<br />

• The clinical supervisor shares conflicts with staff, personal issues or his or her<br />

own frustrations about clients in a non-professional manner.<br />

• Conflicts occur with team members who are attending the supervision and others<br />

who are outside of the group. (It is helpful to have strategies to address this within<br />

the group.)<br />

Importance of trust and safety in group supervision<br />

The development of trust and safety may be impeded when a member of the group<br />

takes on the role of “consultant” (i.e., the person who is never listening, always “one<br />

upping” other team members, or giving an answer or suggesting a “better” approach).<br />

For example, group members who do not take risks, who only present the cases<br />

they are not having difficulty with and do not reflect on their own practice in group<br />

supervision tend not to bond with the group. Trust and safety in the group may be<br />

compromised when the members vary significantly in their approaches to practice,<br />

and/or when members come from a variety of disciplines with varied levels of<br />

experience.<br />

Open vs. closed group<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Providing group supervision on an inpatient unit with an interdisciplinary team<br />

requires some flexibility due to nurses’ schedules. Having a closed group requires<br />

nurses to come in on days off. Open groups accommodate a variety of schedules.<br />

However, they present other challenges.<br />

In an open group, participants may be reluctant to self-disclose. How much a clinician<br />

chooses to self-disclose often depends on the cohesion of the group as a whole and the<br />

mix of staff attending the group that day. Closed groups can achieve a greater sense of<br />

cohesiveness and safety, making it easier for staff members to expose their vulnerability.<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

Other disadvantages of open groups include an absence of focus and the need to<br />

repeat content. In a closed group, clients can be discussed over time, with more<br />

opportunities for clinicians to report on results of following through on recommendations<br />

and the insights that emerge during group clinical supervision. When the<br />

group is open, this kind of continuity is more difficult. The clinical supervisor needs<br />

to deal with the needs of the group generated by the most emergent needs of clients<br />

currently on the unit.<br />

Five tips to successful open-ended groups<br />

1. Review group norms for every group meeting and have a handout<br />

available that outlines the norms.<br />

2. Offer group members an opportunity to provide a case outline<br />

for any ongoing case.<br />

3. Obtain feedback from all staff on a regular basis both from<br />

those who attend and those who do not to assess the effectiveness<br />

of the group.<br />

4. Ensure that there is a focus from group to group relevant to all<br />

participants and be prepared with potential topics for discussion<br />

(e.g., ethical dilemmas), should the group have difficulty<br />

identifying a focus.<br />

5. Avoid repetition of content because group members who<br />

attend regularly may get bored and frustrated.<br />


Strategies to promote group cohesion<br />

Structure<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

• Teach group skills and how they relate to group rationale and goals for group<br />

supervision.<br />

• Clarify purposes of the group (informational, educational, administrative).<br />

• Explain how clients will be discussed, group norms, structure, how feedback will<br />

be given and received, how time is shared, how conflict and competition in the<br />

group will be handled.<br />

Group process<br />

• Encourage open communication about current and immediate issues among<br />

group members, such as group tensions.<br />

• Intervene to ensure that group norms are respected.<br />

• Provide leadership by modelling and identifying facilitative group member<br />

behaviours, such as risk taking, and providing constructive feedback.<br />

• Facilitate focused discussion and feedback.<br />

• Provide supportive and helpful feedback.<br />

• Ensure that feedback about practice is balanced and focused and propose<br />

possible next steps.<br />

• Encourage team members to respond to each other’s concerns in a positive<br />

manner.<br />

• Ask direct questions regarding clinician’s experiences if soliciting ongoing group<br />

feedback is a challenge, such as “sometimes clinicians can feel overly criticized<br />

in group supervision. Are any of you having that experience in this group?”<br />

This targeted feedback may encourage more group level disclosure because it<br />

normalizes clinicians’ concerns.<br />

• Validate different perspectives and approaches and stages of learning.<br />

• Rework formative stages of group process.<br />

• Discuss what is and is not working in the group process.<br />

• Provide time for critical reflection on practice and integrate theory and practice<br />

in each session.<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

Yalom’s therapeutic factors and group supervision<br />

• Yalom’s therapeutic factors are listed below and described in relation to the experience<br />

of being a member of a supervision group:<br />

• Instillation of hope: Within the context of group supervision, clinicians get a<br />

sense that there is light at the end of the tunnel when working with challenging<br />

clients. Hearing the experiences of others can highlight progress that the presenting<br />

clinician might have lost sight of because he or she has lost some objectivity.<br />

• Universality: A sense that clinicians are not alone in the work they are doing and<br />

how they are feeling. Feeling validated from other clinicians who discuss similar<br />

experiences with clients.<br />

• Imparting of information: Providing information to others about the client, how<br />

to work with them or the process of self-reflection.<br />

• Altruism: Having the opportunity to help other staff.<br />

• The corrective recapitulation of the primary family group: Traumatic re-enactments<br />

play out in the team based on the clients projected experiences, power differentials<br />

within the team and how these are processed, parallel process and how conflicts<br />

are managed within the team.<br />

• Development of socializing techniques: Learning how to communicate with one<br />

another within the team using interpersonal feedback and constructive feedback<br />

without judgment.<br />

• Imitative behaviour: Learning how other team members work with clients and<br />

each other by observing what they say and do in supervision.<br />

• Catharsis: An opportunity to vent and label feelings.<br />

• Existential factors: Issues that come from the person’s confrontation with the<br />

“ultimate concerns of existence”: death, freedom, isolation and meaninglessness.<br />

In working with clients, a significant existential issue that clinicians encounter<br />

over and over again is human suffering. Having an opportunity to process these<br />

issues is helpful to clinicians who may otherwise feel overwhelmed.<br />

• Cohesiveness: The sense of belonging and value within the team.<br />

• Interpersonal learning: How the team interacts with one another in the here<br />

and now while discussing a client can be a reflection of the client’s relationships<br />

in the world outside (e.g., staff that takes on the negative aspects of the clients,<br />

those who are the vessels of the positive) (Yalom, 1995).<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

An example of group clinical supervision<br />

We find that the clinicians’ experience is most helpful and safe when it is structured<br />

in such a way that the expectations of all participants and what is expected of the<br />

participants are clear. This allows them to come to the sessions prepared, understanding<br />

their roles in the context of the person requesting assistance and giving<br />

constructive feedback to others.<br />


The clinician begins by presenting a clinical dilemma in the form<br />

of a question so the group has a frame of reference before hearing<br />

about the client. An example of this would be, “I would like<br />

your help with the client I am going to present. I am feeling stuck<br />

and would welcome your ideas about how to help the client consider<br />

some other alternatives.” Another example might be, “This<br />

client is feeling overwhelmed with many stressors in her life. She<br />

isn’t working. Her kids are a handful for her. She does not feel<br />

safe where she is living. She continues to have flashbacks and<br />

nightmares. When I listen to her, I don’t know where to start.<br />

I feel overwhelmed myself. I would welcome your ideas.” The purpose<br />

of introducing this question is to keep the feedback focused,<br />

diminishing the possibility of a “free-for-all.” Other clinicians<br />

might ask several questions that do not address the needs of<br />

the clinician and assume the clinician has not already covered or<br />

considered what is being asked. After the question / dilemma<br />

is put forward, the clinician presents some background on the<br />

client (e.g., major concerns, history of her or his work with<br />

the client, attempted solutions—material that directly relates to<br />

the question).<br />

As the clinician receives feedback from the group, he or she takes<br />

notes and then shares what most stands out and what specifically<br />

was gleaned from the consultation. The clinician then discusses<br />

what she or he would like to try and how it might be helpful. The<br />

clinician will then make a note of this recommendation in the<br />

progress note or on the Interdisciplinary Plan of Client Care.<br />

In a round table format, each person is invited to ask one question<br />

of the clinician once he or she is finished providing the overview.<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

Individuals may pass if they do not have a question. Specific<br />

questions are intended to help the other consultants develop an<br />

understanding of the client. The clinician provides brief answers<br />

to the questions and makes a special note of questions he or she<br />

cannot answer, as these may be keys to future possible solutions<br />

to consider. Examples of questions could be, “What happens<br />

when you suggest the strategies that you have with your client?”<br />

“Do you know if she has had similar experiences within other relationships?”<br />

“Do you know about the community resource that<br />

can help her with…?” If individuals wish to do a second or third<br />

round of questioning (depending on the size of the group), they<br />

may do so, again with options to pass. The discussion is opened<br />

up to everyone, and ideas offered in a spirit of curiosity. This is an<br />

important point to emphasize so that clinicians don’t feel as<br />

if their colleagues are attacking them or that the questions are<br />

coming from a place of judgment and competition rather than a<br />

desire to be helpful.<br />


Individual clinical supervision is the most widely used model of clinical supervision<br />

in social work practice (Kadushin & Harkness, 2002), and has been described by<br />

nurses as a valuable process providing the time to reflect on and learn from their<br />

practice (Teasdale et al., 2001; White et al., 1998). Nursing best practice guidelines<br />

for establishing therapeutic relationships recommend the provision of clinical<br />

supervision to support the establishment of therapeutic relationships between<br />

nurses and clients (rnao, 2002). <strong>Clinical</strong> supervision is an opportunity to help and<br />

support clinicians to reflect on clinical dilemmas, challenges and successes; and to<br />

explore how they responded to, solved or achieved them (Cutcliffe & Lowe, 2005).<br />

It is a forum for considering the personal, interpersonal and practical aspects of<br />

care to develop and maintain clinicians who are skilled and self-reflective (Cutcliffe<br />

& Proctor, 1998).<br />

In individual clinical supervision, concepts crucial to the development of therapeutic<br />

relationships with clients, such as trust, respect, empathy, empowerment and a nonjudgmental<br />

approach are understood by developing a trusting, supportive relationship<br />

with a clinical supervisor. The supervisory process is like a journey as clinical supervisor<br />

and clinician explore clinical material together, with a view to arriving at a deeper,<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

more meaningful understanding of the client. In this way, the supervisor-clinician<br />

relationship parallels the clinician-client relationship.<br />

Beginning individual clinical supervision<br />

The first task of the clinical supervisor is to create a safe space in which the clinician<br />

can re-experience clinical difficulties and the feelings associated with them. Creating a<br />

safe space and a supervisory alliance with the clinician involves developing a trusting<br />

relationship and providing education regarding clinical supervision: what it is and<br />

how it works (Gallop, 2004). This is particularly important because clinicians will<br />

bring their own perceptions of clinical supervision to the supervisory relationship.<br />

Exploring previous experiences with clinical supervision and the feelings associated<br />

with these will provide an opportunity to correct any misconceptions that the clinician<br />

has about the supervisory process. Even if the clinician has not had clinical supervision<br />

before, it will be important to explore preconceived notions about it. The word<br />

supervision itself may conjure up negative feelings, particularly from nursing staff<br />

where historically, it was associated with management and surveillance. On the other<br />

hand, social workers view clinical supervision as a crucial component of their practice.<br />

Education regarding supervision should also establish clear boundaries by not only<br />

addressing what clinical supervision is, but also addressing what it is not; for example,<br />

clinical supervision is not personal therapy. The focus is on the clinician-client<br />

relationship. Having said that, there may be times when personal issues are having<br />

an impact on the clinician-client relationship and this needs to be acknowledged.<br />

A safe space is further constructed by scheduling regular time to meet with the clinician<br />

in a private place, such as the supervisor or clinician’s office. Scheduling a minimum<br />

of 45 minutes to one hour every four weeks for individual clinical supervision is<br />

recommended in the nursing literature (Butterworth et al., 1997; White et al., 1998)<br />

while social work supervision is usually provided weekly or every second week.<br />

Winstanley and White (2003) note that clinicians in monthly or bimonthly sessions<br />

scored higher on the Manchester <strong>Clinical</strong> <strong>Supervision</strong> Scale (Winstanley, 2000), a scale<br />

that measures the effectiveness of clinical supervision. <strong>Supervision</strong> time is protected,<br />

uninterrupted time that both clinical supervisor and clinician respect. The clinical<br />

supervisor demonstrates his or her availability, consistency, respect and reliability<br />

by being present and punctual, which not only serves to establish a trusting, safe<br />

relationship with the clinician but also models qualities that clinicians ideally transfer<br />

to their clinical practice to build therapeutic relationships with their clients. Some<br />

clinicians may be reluctant to engage in scheduled supervisory sessions or may feel<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

they cannot take time away from a busy inpatient unit. These clinicians may prefer<br />

more informal support at least as a starting point to building trust and engaging in<br />

more formal clinical supervision (see Spontaneous <strong>Supervision</strong>, p. 66). Additionally,<br />

engaging inpatient nursing staff in particular in individual clinical supervision can<br />

be challenging due to unit constraints (see Nursing and <strong>Clinical</strong> <strong>Supervision</strong>, p. 75).<br />

Confidentiality is critical to the development of a safe and trustworthy environment.<br />

The clinical supervisor explains that discussions in the sessions are confidential. The<br />

only time this confidentiality is broken is if the clinician has been involved in unsafe<br />

or unethical behaviour with a client. The supervisor must confront such behaviour.<br />

Ideally, the supervisor helps the clinician identify the problem and initiate corrective<br />

action. The supervisor monitors the process (Gilmore, 2001). If supervision has been<br />

mandated, the supervisor is obligated to share information with the manager. (See<br />

When <strong>Clinical</strong> <strong>Supervision</strong> is at the Request of the Manager, p. 28). A strong confidential<br />

ethic contributes to a safe environment. Without the establishment of a safe<br />

environment, the clinical supervisor and clinician will be less likely to explore the<br />

more risky aspects of unprofessional practice (Epling & Cassedy, 2001).<br />

A discussion of goals is important to the development of a focus for clinical supervision<br />

sessions (see Beginning of the Relationship and Contracting, p. 23). Clinicians<br />

may come with very specific goals, such as addressing difficulties experienced while<br />

caring for a particular client, a client population or diagnosis, or they may require<br />

assistance in exploring and developing their goals within a framework of clinical<br />

supervision. Frameworks or models of supervision within both nursing (Proctor,<br />

1991) and social work (Kadushin, 1976) frequently include the components of<br />

support, education/learning and administration, and supervision is described as a<br />

reflective process (see Appendix 1, a review of the literature, pp 103). It is important<br />

to note, as Fowler and Chevannes (1998) suggest, that some clinicians may not be<br />

ready to or able to cope with intense examination of themselves and their work. If the<br />

clinician is inexperienced clinically, then a focus on reflection may not be appropriate,<br />

at least not initially. A more directive approach such as a preceptorship may better<br />

meet the clinician’s goals, with clinical supervision being available when the clinician<br />

is more experienced.<br />

The opportunity to off-load in the context of a supportive relationship builds trust<br />

and a foundation for later exploring clinical material in more depth. Caring for<br />

clients living with mental illness and/or addictions is hard work. Listening to clients’<br />

stories and bearing witness to their pain and suffering can take a toll on clinicians<br />

and contribute to burnout and low morale. Novice clinicians may be particularly<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

vulnerable to feeling alone and overwhelmed. An affirming and empathic supervisory<br />

experience can enhance morale and increase self-confidence. It provides a starting<br />

point, and a strong foundation in which the clinician feels safe, supported and gradually<br />

is able to take more risks within the relationship. Similarly, this opportunity to<br />

off-load and receive support is critical in the development of a therapeutic alliance<br />

with clients. In this way, the supervisor-clinician relationship mirrors the clinicianclient<br />

relationship as an experience of feeling comforted and understood.<br />

The working phase of individual clinical supervision<br />

Once a trusting, safe foundation is established, the clinical supervisor and clinician<br />

begin the process of exploring and understanding thoughts and feelings, such as<br />

those experienced by the clinician toward the client, and the client toward the clinician.<br />

Developing a deeper understanding enables the clinician to respond in a less<br />

emotionally reactive and more conscious, thoughtful manner to the client (Gallop,<br />

2004). Ideally, it is the clinician or the supervisor-clinician dyad that arrives at this<br />

deeper understanding of a particular client situation. If this doesn’t happen, the clinical<br />

supervisor may need to take a more directive approach at least in the earlier<br />

stages of supervision. The process of journeying together is modelled by the clinical<br />

supervisor, as illustrated in the vignette below, and is empowering to the clinician. In<br />

the clinician-client relationship the therapist models a similar process of journeying<br />

with the client, as issues are explored and better understood.<br />

Part of the journey includes the development of self-awareness in the clinician and a<br />

recognition that his or her own experience is influenced by multiple factors such as<br />

race, culture, health, socio-economic conditions, gender, education, early childhood<br />

experiences, current relationships, beliefs and so on. With the development of this<br />

self-knowledge the clinician is better able to distinguish between her own experience<br />

and values, and those of her client. “In this way, she is able to appreciate the unique<br />

perspective of the client, is able to avoid burdening the client with her issues, and<br />

can prevent imposing her own beliefs and preferred solutions upon the client”<br />

(rnao, 2002).<br />

The following example illustrates some of the concepts discussed so far.<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />



A nurse on an inpatient unit met with her supervisor to discuss a<br />

client with whom she was having difficulty engaging. This client<br />

had a chronic mental illness and also suffered from diabetes. The<br />

nurse described her interactions with the client and talked about<br />

how she was focusing on the client’s diabetes, which was not well<br />

controlled, and her mental illness. She herself felt as though she<br />

was “nagging” the client “all the time” about the importance of<br />

following a diet to better control her diabetes. The client became<br />

withdrawn and uncommunicative in her interactions with the<br />

nurse. The nurse said she had reached an impasse with this client.<br />

The clinical supervisor explored the nurse’s feelings, as well as<br />

how the client may have been feeling. The nurse felt like a<br />

“nagging parent,” constantly pointing out to the client what she<br />

ought to be doing. She cared for the client and was fearful that the<br />

client’s health would deteriorate further, and she would never get<br />

better if she did not adhere to her dietary and treatment regime.<br />

She also felt a sense of urgency and responsibility, given her timelimited<br />

involvement with the client as an inpatient nurse. If the<br />

client didn’t get better, she wasn’t doing a good job. The client,<br />

she thought, may have felt powerless, frustrated and tired of<br />

“being a patient.” The nurse and the clinical supervisor began to<br />

wonder if her focus on the client’s illness was interfering with her<br />

seeing the client as a whole person and with getting to know her,<br />

beyond her illness. Perhaps that is why the client had withdrawn.<br />

Together they explored an empathic perspective and tried to see<br />

and feel the world as her client was seeing and feeling it. They<br />

wondered: what was it like for her to be ill and in hospital? How<br />

did it feel for her to have so much of her life revolve around “being<br />

a patient”? How did it feel for her to be dependent on others for help<br />

indefinitely? By trying to experience the client’s world from her<br />

perspective, they came up with an intervention aimed at helping<br />

the nurse reconnect with her client. This involved taking the client<br />

off the unit, perhaps for a walk or to the coffee shop (the client<br />

would decide on the activity) in a “less illness” focused context<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

and trying to engage her around non-illness related topics—getting<br />

to know her as a person, her hopes, her dreams, her interests,<br />

her past and so on.<br />

For the next four weeks, the nurse did this. When the clinical<br />

supervisor met with the nurse again she described the process<br />

and outcome. The client chose the coffee shop and they made a<br />

point of going there to “chat” at least once a week. The nurse<br />

refrained from discussing the client’s illness during these outings,<br />

and instead explored topics of interest to her client—they talked<br />

about what her life was like before she became ill, how she liked<br />

to dress and wear her hair; and her dream to work as a hair stylist.<br />

These outings to the coffee shop became important to the client<br />

and she looked forward to them. The nurse noticed that over the<br />

course of the next four weeks, her client became much less defensive<br />

with her on the unit, and more relaxed. She started to pay<br />

more attention to her dress and her appearance. Eventually she<br />

was receptive to the nurse addressing her illness issues again.<br />

When the client was discharged from the hospital she gave the<br />

nurse a coffee mug. The clinical supervisor and nurse discussed the<br />

significance of this, an affirmation that these trips to the<br />

coffee shop had been meaningful to the client and had contributed<br />

significantly to them working together therapeutically to<br />

achieve a positive outcome.<br />

This clinical situation highlighted for the nurse the limits of her<br />

role and resulted in her understanding more clearly that she<br />

could not “control” the client. By taking a holistic approach to the<br />

client, getting to know her beyond the illness, she communicated<br />

respect for her client as a person, understanding and a hopefulness<br />

that facilitated the therapeutic relationship and contributed<br />

to the client’s recovery. This example demonstrates how concepts<br />

such as holistic care, empathy and recovery are woven into the<br />

supervisory process. For the nurse, these concepts are brought to<br />

life and more deeply understood as they are experienced in the<br />

context of a real therapeutic relationship.<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

Another example highlights the concept of empathy and its role in developing therapeutic<br />

relationships.<br />



A clinician was providing care to an outpatient, a young woman<br />

who was recovering from a first episode of psychosis. All<br />

attempts to engage her in a dialogue about the illness and discuss<br />

the need for ongoing medication had failed. The client<br />

would “shut down” and repeat very defensively that she was fine<br />

and she didn’t need to talk about this.<br />

When the clinician met with her clinical supervisor, she shared<br />

her frustrations about the client not being receptive to her health<br />

teaching and education about her illness. The clinical supervisor<br />

acknowledged her frustration and explored her feelings, further<br />

revealing the clinician’s concerns about this client becoming ill<br />

again if she did not develop insight into her illness. Together, they<br />

stepped back and tried to look at the situation from the client’s<br />

perspective. The clinical supervisor asked the clinician to tell her<br />

more about this young client. The clinician described a young<br />

woman who had just experienced a first episode of psychosis.<br />

She had been functioning well prior to the illness, attending<br />

university and had lots of friends. She had to take time off university<br />

to recover from her illness, and felt cut off from her friends. The<br />

clinician and clinical supervisor talked about how the client now<br />

had to come to terms with having suffered a highly stigmatizing<br />

illness that had significantly interrupted her life. They talked<br />

about the implications of her illness, which included an uncertain<br />

future. Together they arrived at a more meaningful understanding<br />

of what might be going on inside this young woman.<br />

The next time the clinician met with her client the following interaction<br />

unfolded:<br />

Clinician: “I’ve been thinking about our meetings and have realized<br />

that I’ve been talking a lot about the importance of medication in<br />


preventing further illness episodes. And I’ve noticed that isn’t of<br />

much interest to you right now.”<br />

Client: nodded her head in agreement<br />

Clinician: “I’m wondering how you’re feeling about this illness<br />

right now (pause) and I’m thinking that it must really suck. It’s<br />

really interrupted your plans.”<br />

Client: Tears start to well up in her eyes as she says angrily, “I hate<br />

it. I don’t want to take medication. I don’t want to be sick. Why<br />

can’t things just be the way they were before? It’s just not fair!”<br />

Clinician: “Yes. You’re right. It’s not fair. It’s awful when something<br />

disrupts your life like this, especially an illness. I can understand<br />

why you feel so angry and sad and just want it all to go away.<br />

Client: nods and begins to weep.<br />

This vignette illustrates how an empathic approach allowed the clinician to attend to<br />

the subjective experience of the client and validate that her understanding was an<br />

accurate reflection of the client’s experience. She gained entrance to the client’s inner<br />

world and was able to better understand the client’s experience. The result was a<br />

strengthening in the bond between the clinician and client as the client felt the comfort<br />

of being understood. This interaction opened the door to addressing the client’s<br />

experience of illness and the meaning it had for her. The client no longer felt that<br />

the clinician was “pushing” her agenda onto the client. Eventually, the client was able<br />

to negotiate with the clinician and her psychiatrist a medication regime that she the<br />

client felt comfortable with.<br />

Boundaries<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Clinicians have an obligation to put client needs before their own and to act in the<br />

client’s best interests. “Sometimes, our own conscious or unconscious wishes make<br />

it hard to recognize boundary violations” (rnao, 2002). A very important function<br />

of individual clinical supervision is the development in the clinician of an awareness<br />

and understanding of the boundaries and limits of the professional role. This understanding<br />

of boundaries is crucial to providing safe and ethically sound clinical<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

practice. Within a safe and trusting relationship, the clinician can explore the client’s<br />

thoughts and feelings related to the client, and discuss behaviours that may indicate<br />

the crossing of boundaries, such as spending extra time with clients, having special<br />

clients, or doing activities with clients that the clinician does not share with colleagues.<br />

In this way, clinical supervision is a proactive process that can prevent boundary<br />

transgressions. Proctor (1991) refers to this function of clinical supervision as “normative.”<br />

Normative supervision is concerned with promoting high quality care and<br />

reducing risks. The supervisor is obligated to confront any situation or practice he<br />

or she feels is unethical or unsafe. As mentioned previously, an ideal process is one<br />

in which the supervisor facilitates the clinician to identify the problem and initiate<br />

corrective action.<br />

Transference, countertransference and parallel process<br />

As supervision moves beyond the initial stages of developing trust and safety, a more<br />

in-depth understanding of the client is achieved by exploring the processes of transference,<br />

countertransference and parallel process. Transference refers to a process in<br />

which the client transfers past or present attitudes and feelings toward family members<br />

or other important persons in their life onto the clinician. It may be positive or negative<br />

and, in classic psychoanalytic literature, is described as an unconscious phenomenon.<br />

Clients may repeat interaction patterns characteristic of earlier relationships in their<br />

relationship with the clinician. The client’s transference is important to explore with<br />

the clinician as it contributes to greater understanding of the client’s difficulties. For<br />

example, one might speculate that the client in the first vignette developed a negative<br />

transference toward the nurse responding to her like a critical parent may have in<br />

the past. The nurse, feeling as though she was “nagging” the client, and the client’s<br />

subsequent withdrawal from the relationship, supports this notion.<br />

Countertransference refers to thoughts and feelings experienced by the clinician toward<br />

the client. Countertransference may also be experienced by the supervisor toward<br />

the clinician, and by the clinician toward the supervisor. Similar to transference, these<br />

feelings may be positive or negative. Before any exploration of countertransference,<br />

it is crucial that there be a trusting relationship between clinical supervisor and<br />

clinician. The clinical supervisor must also be cognizant of maintaining the boundaries<br />

of the supervisory relationship. “The guiding principle is that all discussion<br />

relates to the client. If the supervisor or supervisee sees a drift towards exploration<br />

of factors relating to the supervisee’s relationships and life apart from reactions<br />

to and feelings about the client, the supervisor should stop, rethink, and consider<br />

alternatives.” (Falender, 2006, p. 39)<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Parallel process refers to changes in the supervisor-clinician relationship that relate<br />

to dynamics in the clinician-client relationship; in other words, it involves a series<br />

of transference-countertransference interactions. The supervisor needs to be alert to<br />

changes in the clinician’s mood or behaviour, as well as feelings within him- or herself.<br />

Such changes may indicate that a parallel process is taking place (Gallop, 2004).<br />

Grey and Fiscalini (1987) note that the motivation for the clinician engaged in parallel<br />

process with the clinical supervisor is that by acting like his client he is trying to<br />

communicate information not consciously accessible, or that he is trying to see how<br />

the clinical supervisor would handle the situation.<br />

An example is described in the following vignette.<br />



A social worker was involved with a client on an inpatient unit,<br />

and his wife. He described to the clinical supervisor the conflict<br />

this couple was experiencing and the events that led up to a<br />

restraining order being issued by the court prohibiting the husband<br />

from having any contact with his wife. This followed a physical<br />

assault by the husband. The social worker described his experience<br />

of working with this client and the couple. The husband<br />

and wife, although physically apart, continued to communicate<br />

indirectly through the social worker. He found himself in the role<br />

of intermediary between the wife and the husband. As the social<br />

worker described the relationship and his involvement as an<br />

intermediary, the supervisor began to find it difficult to follow.<br />

She had to frequently seek clarification from the social worker as<br />

his communication became increasingly convoluted and she<br />

becoame increasingly confused. She shared her confusion with<br />

the clinician and asked if this was how he was feeling in his work<br />

with this couple.<br />

This led to a discussion of the social worker’s role with this couple,<br />

including the boundaries of his role, and the couple’s conflict,<br />

ambivalent feelings and hidden agenda that seemed to be getting<br />

played out through the social worker. Afterward, the clinician felt<br />

less burdened and was able to focus more clearly on the boundaries<br />

of his role with this couple and set clear limits. He also<br />


ecognized the limitations of his professional involvement and<br />

more clearly understood what could realistically be achieved with<br />

this couple during a brief inpatient stay.<br />

Authority and dependency issues are frequently at the root of parallel processes<br />

(Grey & Fiscalini, 1987). If the clinical supervisor and clinician don’t explore<br />

motivations for engaging in this process, they may get stuck in a series of transferencecountertransference<br />

interactions. Grey and Fiscalini (1987) state that this is avoided<br />

if the clinical supervisor empathizes with the clinician, but does not get stuck in<br />

the empathic process. The clinical supervisor is able to see the client and clinician’s<br />

perspectives, and differentiate them from his or her own. The supervisor is then able<br />

to clarify the transference-countertransference interplay occurring. However, if the<br />

clinical supervisor does get caught up in a parallel process, he or she can use his or<br />

her own emotional response to explain the anxiety in the clinician-client dyad and,<br />

additionally, the anxiety in the supervisor-clinician dyad.<br />

Exploring transference, countertransference and parallel process as they emerge<br />

within the supervisory relationship and clinician-client dyad ultimately illuminates<br />

a deeper, more meaningful understanding of the client.<br />

Conclusion<br />

Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

Individual clinical supervision, when conducted in the context of a supportive, trusting<br />

relationship, is a vital process that contributes significantly to quality client care.<br />

As the clinician’s capacity to engage in reflective practice grows, so too does his or<br />

her ability to establish therapeutic relationships with clients. The supervisory process<br />

is a journey that clinical supervisor and clinician embark on together. It is a journey<br />

that in so many ways models the clinician-client relationship by introducing experientially<br />

concepts critical to the development of healthy and therapeutic relationships<br />

with clients such as empowerment, empathy, trust and boundaries. The supervisory<br />

process and the client are better understood through discussions of transference,<br />

countertransference and parallel process as they emerge along the way. While taking<br />

time out of one’s busy schedule to participate in or conduct clinical supervision<br />

may at times seem challenging, this is time well spent, particularly when one sees<br />

the positive outcomes for clients, the therapeutic impasses that are overcome, and<br />

the boundary transgressions that are avoided.<br />




Presenting a case to a supervisor and / or colleagues helps clinicians organize information<br />

about treatment into coherent themes and concepts. It also gives the clinical<br />

supervisor a chance to evaluate which areas of practice and client management the<br />

clinican has mastered and which could be improved or enhanced (Ask & Roche,<br />

2005) There are many ways that case presentations can be structured. The following<br />

section describes the approach used by one camh program.<br />

Using the Core Conflictual Relationship Theme<br />

The clients of a camh program that provides inpatient and outpatient transitional<br />

care treatment for women with a mood disorder associated with a history of interpersonal<br />

trauma (childhood and/or adulthood physical, emotional and/or sexual<br />

abuse often experience the consequences of trauma including substance abuse, selfharm<br />

behaviour and dysfunctional interpersonal relationship patterns. Because they<br />

experience these problems within their relationships, the Core Conflictual Relationship<br />

Theme (ccrt) and the consideration of feminist themes are used as frameworks to<br />

enhance clinicians’ understanding of the client’s dynamics.<br />

Luborsky (1997) believed that the ccrt was a valuable approach to setting treatment<br />

goals in short-term hospital settings. It provides a way of both clinicians and clients<br />

increasing their understanding of the client’s relationship difficulties and ways of<br />

overcoming them. The ccrt method is based on the principle that redundancy across<br />

relationship narratives is a good basis for assessing the central relationship pattern.<br />

A relationship pattern consists of:<br />

• the person’s wish in relationships<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

• what they experience as the reaction of others (RO) to them<br />

• how they respond to these reactions (the reaction of self (RS).<br />

People generally approach relationships with a wish for something particular from<br />

the other person (e.g., the wish to be loved, validated or generally cared for). They<br />

experience others responding to them in particular ways (e.g., loving, abusive, silencing)<br />

and they react in kind (e.g., withdraw, push the other person away in anger). Through<br />

describing different relationships, the clinician and client can see patterns emerge.<br />


The pattern is the ccrt (e.g., the client yearns to be loved and noticed but finds that<br />

most people in her life are abusive in different ways. She reacts by withdrawing and<br />

thus experiences loneliness and isolation).<br />

Using the ccrt as an organizing framework, the clinician preparing to present his or her<br />

client would come to the clinical supervision session with the following information:<br />

• client’s initials<br />

• number of sessions (when the client being presented was part of an outpatient<br />

program) or date of admission for inpatients<br />

• identifying data<br />

• age<br />

• history relevant to concerns client is expressing<br />

• relationship experiences/status<br />

• issues related to diversity<br />

• client belief system<br />

Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

Provisional ccrt<br />

Wish 1: to be heard and validated for who she is, to have a sense of self, to be able to<br />

establish more effective boundaries<br />

RO (response of others) 1: ignore her, tell her what to do, beat, humiliate or<br />

abandon her<br />

RS (response of self to others’ reaction) 1: feels angry, withdraws, feels like she<br />

cannot make her own decisions and relies on others to do so, feels depressed, pushes<br />

people away, feels silenced<br />

Wish 2: to be taken care of (if I were wealthy, I could live the kind of life I want)<br />

Associated feminist themes: violence, patriarchy, powerful feminine figures (goddess,<br />

grandmother), emphasis on appearance as a measure of worth<br />

RO 2: “You are stupid.” “You do not deserve to live.” “You cannot do what you want<br />

to do (travel, dance).”<br />

RS 2: not take advantage of opportunities, withdraw, “I am too tired to make changes,”<br />

“I am stupid” pushes people away by being difficult to be with or saying she does not<br />

want to commit<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

In addition to the above, clinicians in this program consider information related to<br />

traumatic re-enactments. With this comes the understanding that a common feature<br />

in these clients’ relationships are the roles of perpetrator, victim and rescuer and<br />

how the client can assume these roles interchangeably with others in their lives based<br />

on their childhood experiences. This includes their relationships with clinicians.<br />

After presenting this information to the clinical supervisor and the group, the team<br />

and the clinician working with the client have a better understanding of the underlying<br />

dynamics and can use this to help the client look at alternatives and make sense<br />

of how this pattern continues to be problematic.<br />

Adapted from Luborsky, L. (1997). In T. D. Eells (Ed.), <strong>Handbook</strong> of Psychotherapy Case Formulation: The Core<br />

Conflictual Relationship Theme. New York, NY: The Guilford Press.<br />



Using the lighthouse as a metaphor for the clinical supervisor presents the image<br />

of a steady beacon for temporarily lost and stranded ships in the fog. The clinical<br />

supervisor can provide direction, guidance and support for safe passage when it is<br />

most needed. The lighthouse connotes a symbol of leadership, assurance, safety<br />

and hope.<br />

In the busy life of a program, it’s important to consider how adhering to a too-rigid<br />

definition of clinical supervision may be a barrier to staff receiving important support<br />

in their work. Requests for clinical supervision can come in many forms. Important<br />

supervision issues, especially in an inpatient setting, often arise spontaneously and,<br />

although it may be unrealistic to expect that the supervisor can provide a totally<br />

comprehensive supervision in a short time (within 10 to 20 minutes), unscheduled<br />

conversations about client care can be consistent with a traditional definition of<br />

clinical supervision. These conversations may also be a starting point for more formal<br />

supervision. Supervisors should be encouraged to consider multiple, brief clinical<br />

conversations that include Socratic questions, affirmation of the supervisee’s skills<br />

and capacities, and promoting client-centred care within a program—as very real<br />

examples of clinical supervision. In other words, the sum of multiple effective contacts<br />

can equal or exceed one scheduled formal session.<br />

If supervision is limited to scheduled conversations, many opportunities for responding<br />

to staff needs for consultation will be lost. Staff needs for support, education and<br />

guidance cannot be totally addressed without this more open access to the clinical<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

supervisor. Access to the supervisor can be a good way for staff members to flag<br />

issues as they arise and to sort out which ones need to be addressed in the moment<br />

and which ones warrant a more full exploration in scheduled supervision.<br />

In the realm of established and formal clinical supervision, one could argue whether<br />

“clinical supervision on the fly” or “spontaneous clinical supervision” has validity.<br />

Given a culturally diverse staff makeup, along with varying degrees of competency<br />

levels, some staff members may seek spontaneous clinical supervision while others<br />

prefer scheduled supervision. Historically, many nursing staff have come to associate<br />

scheduled supervision with disciplinary action. In such a context, spontaneous<br />

supervision provides a mechanism for clinicians to introduce supervision issues<br />

ahead of time. This may be less of a concern for newer nursing graduates with more<br />

experience at receiving formal supervision than for nurses who may have begun<br />

practising at a time when supervision was associated with discipline. Currently,<br />

nurses receive mentorship during their training and expect it from designated senior<br />

colleagues or their direct supervisor.<br />

Another way of viewing spontaneous clinical supervision is as a vital component<br />

of the life of an inpatient unit in which traditional, scheduled supervision may not<br />

be realistic. Some of the benefits of spontaneous supervision can include reduction<br />

of feelings of isolation on the part of staff and alleviation of feelings of anxiety that<br />

may arise during the work day. One observable factor when assessing how staff<br />

members learn is the use of self-reflection, which might be more familiar for the<br />

allied health professionals. This may be new to some nurses, who might view it<br />

as a luxury they do not have time for. Nurses working on inpatient units are often<br />

expected to work at a fast pace, and at times may feel that stopping for reflection<br />

means that they are putting a greater workload on others or are short-changing the<br />

immediate physical needs of their clients.<br />

Critical support in the areas of education and administration is provided when it<br />

is needed. When guided, staff are able to use independent critical thinking through<br />

process and analysis. The clinical supervisor lets staff problem-solve, which promotes<br />

confidence in their ability to function and provide effective service in the moment<br />

and may help to reduce any possible fears of “admitting a mistake.” Professional<br />

growth is observable through attitude change and a positive perspective toward<br />

learning while doing. As one nurse remarked: “there is a sense of renewed hope, which<br />

fosters a sense of belief in myself.” There is no greater motivator than someone<br />

acknowledging your worth as a clinician, as a colleague and as a person. Open recognition<br />

of excellent performance can bring a much-needed smile to even the most<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

isolated staff member. On the floor it can be seen that clinicians shine with a simple<br />

gesture of thanks, “great work on capturing near-misses,” “what a tremendous work<br />

on that eIPCC” or “great job on assisting that client with transition.”<br />

In addition to the support and guidance provided to staff, the supervisor responding<br />

to these spontaneous requests is modelling clinical skills and techniques important<br />

to the development of therapeutic relationships with clients, such as flexibility, availability<br />

and support. Being flexible and available to staff demonstrates an approach<br />

that clinicians can translate into their relationships with clients. The challenge for<br />

the supervisor is knowing when to back off or redirect staff to scheduled sessions.<br />

If staff are only using these spontaneous opportunities and not engaging in more<br />

formal supervision, then the supervisor may want to explore with the staff the possibility<br />

of setting time aside in advance to discuss clinical practice issues.<br />

Spontaneous clinical supervision is not a brief “quick-fix, give-me-the-answer-now”<br />

interaction. It involves critical educational, emotional and clinical support, which<br />

can open the door for follow-up sessions, in which fuller discussions of clinical<br />

scenarios and dilemmas contribute to the growth of the staff member. Spontaneous<br />

supervision does not replace a more traditional model of supervision but offers a<br />

starting point by engaging staff, is flexible and responsive to the needs of staff working<br />

in a busy program, and can also provide an adjunct to traditional supervision.<br />


A clinical supervisor on a long-term care inpatient unit was<br />

approached by the charge nurse, who wanted to take time from<br />

her busy day to visit a patient who had been transferred to a general<br />

hospital for medical investigation. She understood that it<br />

would mean turning the charge nurse responsibilities over to<br />

another nurse for that time, but felt that it was important to<br />

respond to the perceived needs of the individual patient. She did<br />

not have a regular clinical supervision time scheduled for that<br />

morning but showed up at the clinical supervisor’s door to<br />

discuss her plan and its implications. The clinical supervisor<br />

provided support and assisted her in developing and following<br />

through on the plan.<br />


Ongoing <strong>Clinical</strong> <strong>Supervision</strong><br />

The nurse did go to visit the patient and when she returned,<br />

again, flagged down the clinical supervisor because she felt the<br />

need to discuss the case. She reported that her clinical intuition<br />

(although she did not use that term) that a visit by her was needed<br />

was accurate. Because she knew the condition of this patient<br />

so well, she was able to help the staff arrive at the diagnosis of<br />

pneumonia and to provide emotional support for a very ill<br />

patient. This led to a discussion of a recent personal loss for this<br />

nurse and her fears for the future of her patient. This second conversation<br />

only took a matter of 10 to 15 minutes (the nurse needed<br />

to get back to provide noon medications) but in it the clinical<br />

supervisor was able to affirm and support a dedicated staff member<br />

for her clinical assessment and care.<br />



Interdisciplinary <strong>Clinical</strong> <strong>Supervision</strong><br />

In many therapeutic settings, clinical supervision works with groups that include<br />

staff from many different disciplines. At camh, a nurse educator (NE) and an advanced<br />

practice clinician (apc) regularly provide interdisciplinary clinical supervision in a<br />

longer-term unit within the Schizophrenia Program for an inter-professional staff<br />

made up of registered nurses (RNs), registered practical nurse (rpns), social workers,<br />

occupational therapists and recreational therapists. In this section on special issues,<br />

we will start with their experiences.<br />

We would like to begin with two apparently contradictory thoughts. The first is a<br />

quote that was attributed to H.G. Wells. He called professions the “enemy of the<br />

people.” While one wouldn’t necessarily give much thought to the philosophies of<br />

H.G. Wells, the apc heard it in the context of a conference on recovery, in which<br />

professions were being presented as a way in which professionals distance themselves<br />

from their clients and get into unnecessary conflicts with their colleagues. The second<br />

comes from something heard by the apc from a wise supervisor whose professional<br />

training was in social work. She said that every time she felt certain that she understood<br />

nursing she would find that something that the nurses were pointing out as<br />

a big problem was something that she would not have noticed at all. The apc knows<br />

what she means; when providing clinical supervision with the NE, she will ask a<br />

question about nursing clinical practice and it will take her several minutes to understand<br />

what the NE is referring to and why, but the nurses get the importance of it<br />

immediately and the apc eventually does.<br />

So which approach is right? Is it that the divisions between the professions create<br />

unnecessary gulfs between us, making it impossible to really see and care for our<br />

clients, or is it that we need to become more aware of our differences and more<br />

appreciative of one another’s strengths? The NE and the apc have found that it<br />

is both.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

In a busy inpatient unit, clinical supervision goes on all the time. The rhythm of the<br />

day cannot be determined in advance. Beginning first thing in the morning, either<br />

the NE or the apc can be stopped by staff with questions about client care and clinical<br />

practice. At first they would just try to answer quickly, and that still happens at<br />

times, but these ongoing questions provide opportunities for discussing clinical care.<br />

It becomes clear very quickly that the NE and apc will each have slightly different<br />

takes on what needs to happen. That might be a problem except for the respect that<br />

each of them feels for the other—both for the unique clinical perspective that the<br />

other brings to each issue and the trust they have in each other’s caring for clients<br />

and staff. And they cannot stress enough that they also bring shared values for<br />

reflective, client-centred care.<br />

There have been times when a nurse wonders aloud to the NE about the apc’s<br />

understanding of their workload. The message that she gives is that the apc can<br />

appreciate and respect their contribution even if she is not a nurse. This confidence<br />

from the NE in the abilities of a social worker to lead nurses sends a reassuring<br />

message that they have the same goals and values in their work.<br />

So what are the important qualities that make interdisciplinary clinical supervision<br />

work, and even work so well as to bring qualities that are greater than the sum of<br />

one nurse and one social worker? As already discussed, awareness and appreciation<br />

of each other’s professional knowledge base and the trust that each brings the best<br />

of these to her work are important. Implied in that is respect. When either one of<br />

them speak, the other listens and they make this clear to staff. In this way they model<br />

professional respect, including respectful communication, to their staff.<br />


In planning clinical supervision, both the NE and apc spend time reviewing the<br />

strengths of individual staff members, as well as the strengths inherent in professions<br />

they represent. While each profession makes unique contributions to the clients,<br />

there are large areas of overlap, especially in terms of values and goals for clients.<br />

On this particular client care unit, the social workers are the champions of reflective<br />

practice and the big picture of client care; the occupational therapists understand<br />

what clients need to be able to function well in the community; the recreation therapists<br />

are masters at getting clients active after years of inactivity; and the nurses shine<br />

in areas that can seem like a bit of a mystery to the others—what used to be called<br />

patient management, and is now thought of as core nursing practice. As a social<br />


Interdisciplinary <strong>Clinical</strong> <strong>Supervision</strong><br />

worker, the apc often listens in admiration to the attention nurses give to the physical<br />

side of client care. As a nurse, the NE expresses appreciation for the initiative and<br />

willingness of the rest of the staff to address all aspects of a client’s life.<br />



After joining the team, the apc immediately saw the richness of culture on the unit.<br />

The majority of the nursing staff either comes directly from or is descended from<br />

Africa, the Caribbean or South Asia. The apc with the assistance of the NE, have<br />

sought to distinguish and identify the cultural differences and norms within the team.<br />

This has helped in valuing the wisdom in culturally specific traditions, practices,<br />

beliefs and expectations. For example, the apc realized after establishing a working<br />

relationship with the nursing staff that some of the nurses come from a cultural<br />

background where a one-to-one meeting with a supervisor is culturally acceptable;<br />

by contrast, others prefer and seek the benefit of a “group meeting/supervision” to<br />

find the guiding wisdom of the “elder.”<br />


The nurse educator was already providing supervision and leadership on this particular<br />

unit when the apc arrived. They immediately began individual training in the<br />

new electronic plan of client care, the eIPCC. Some of the nurses expressed apprehension<br />

about this training. They felt that their typing and computer skills were<br />

lacking and that the new apc would not respect them. Instead, the apc wanted to<br />

talk about the electronic plan of care as a tool for expressing caring and concern<br />

for clients, beginning with common ground, not technical limitations. The apc was<br />

accustomed to using supervision time to support reflective practice and incorporated<br />

it into the training. She found that some nurses were familiar with this approach<br />

but that there were others for whom the questions the apc would ask opened a new<br />

door to nursing care.<br />

For example, “Client lacks insight into their illness” was a common issue presented<br />

in the plan of care. It might be thought that exploring the meaning of this issue with<br />

the client was providing clinical supervision from a social work perspective. This<br />

introspective approach to clinical supervision has been championed by social workers.<br />

By including it in the training it opened the door to reflection, to looking at the care<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

for the client, and the goals for his or her future, with a wider and deeper lens than<br />

simply making the goal “Client will gain insight into his or her illness.” Why would<br />

that be our goal? What would the client gain from it? Would the client gain anything<br />

from it? Sometimes using oneself as the example will bring insight: Why would it be<br />

important for me to gain insight into my asthma? How would that help my health or<br />

advance me as a human being?<br />

This led to deeper conversations about the needs of individual clients. It seemed<br />

especially important for the nursing staff, some of whom seemed to believe that they<br />

did not have the right to be that involved in their client’s inner life. The importance<br />

of the nurse educator’s support for this approach by the apc cannot be overstated.<br />

Her vote of confidence for this interdisciplinary approach gave the nurses permission<br />

to develop their clinical skills.<br />

An important part of what makes this partnership work so well is the support of both<br />

the manager and the physicians in the program. Everyone in leadership positions on<br />

this particular unit is “on the same page” when it comes to supporting client-centred<br />

care, clear communication and ethical clinical practice. In daily interactions and<br />

clinical directions large and small, the NE and apc feel confident that their work will<br />

be supported.<br />


The nurse educator and the advanced practice clinician are often in the position of<br />

working together on staff leadership. Here is a typical example of a situation in which<br />

the two professions are greater than the sum of their parts. In dealing with a conflict<br />

between two nursing staff members, both the NE and the apc each gravitated toward<br />

different but equally important questions regarding clinical practice. The apc asked<br />

each person to reflect on contributions she might be able to make to improve the<br />

situation. The NE focused on clinical responsibility, asking the RN charge nurse / team<br />

leader how she communicated client assignments. Each asked a different version of<br />

the same question but each elicited different and helpful answers, and together they<br />

gave a full picture of how each person approached their professional practice.<br />

Many staff members on the unit have worked in positions in which professions have<br />

been separate and sometimes competitive. Bringing clinical supervisors from two<br />

different professions together to provide clinical supervision to staff from several<br />

professions means providing an opportunity for staff to appreciate the strengths and<br />


gifts of their colleagues, to learn from one another and improve co-operation in<br />

providing service to their clients.<br />

Nursing and <strong>Clinical</strong> <strong>Supervision</strong><br />

Providing clinical supervision with nurses offers challenges that are unique, particularly<br />

when their work is on inpatient units. As noted earlier, nurses’ experience with<br />

clinical supervision and the meaning attached to it can be different from how social<br />

workers and psychologists see it. For nurses, clinical supervision is often associated<br />

with management rather than clinical practice. For example, nursing supervisors<br />

focus more on operational issues and provide support to staff nurses in the absence<br />

of managers on evenings, nights and weekends around issues such as staffing and<br />

transferring clients between units and to other hospitals.<br />


Nursing and <strong>Clinical</strong> <strong>Supervision</strong><br />

“Reflective practice” is more familiar terminology than “clinical supervision” for<br />

nurses. As members of their professional college, nurses are required to demonstrate<br />

that they have engaged in reflective practice to maintain licensure. This entails being<br />

attuned to the nurse’s own professional needs and ensuring that they obtain the<br />

necessary continuing education to practice competently. Within the college and<br />

university systems, nurses are often asked to reflect on situations with clients in<br />

terms of how they responded, how they understood what went on in light of their<br />

readings/literature, and what alternatives they would consider based on their synthesis<br />

of this information. Analysis of transference and countertransference (see p. 61)<br />

are not generally part of the reflection. A mental health and addiction rotation is<br />

currently not a requirement in training for all undergraduate nursing programs. For<br />

example, one university in Toronto places nursing students at camh in the context<br />

of a “community” experience instead of the more traditional psychiatry placement.<br />




Cleary and Freeman (2005) explored nurses’ perceptions of clinical supervision relative<br />

to other professional support opportunities in acute inpatient mental health settings.<br />

They found that nurses valued having a supportive forum to air their concerns in a<br />

non-judgmental, collegial way, and to discuss practice issues with peers, such as issues<br />

around boundaries with clients. They also viewed dialogue and sharing with their<br />

peers as an opportunity to “reflect on and develop clinical skills” (p. 494). Although<br />

many nurses were aware of the advantages of clinical supervision and supported it in<br />

principle, many preferred informal, ad-hoc approaches with their peers. Most found<br />

it difficult to find the time for clinical supervision, particularly individual clinical<br />

supervision, on a busy, acute care unit and questioned its feasibility. Instead, “informal<br />

support with one’s peers was seen to be more responsive to the clinical realities<br />

of everyday work as generally colleagues were available and accessible” (p. 495).<br />

The clinical supervisor can use this knowledge to help nurses look at the similarities<br />

and differences between what they obtain through these informal means of support<br />

and peer supervision, and what formal clinical supervision can provide. Nurses on<br />

one inpatient unit at camh have identified that although peer support is valuable, it<br />

does not always help them to process their feelings. Hearing others share that they<br />

have had similar feelings and experiences can be validating, but it does not assist<br />

them in seeing connections to their previous personal experiences, wishes or social<br />

location. Sometimes nurses identify with one another’s feelings of powerlessness in<br />

working with a client, making it difficult to gain the objectivity to move beyond<br />

these feelings. The risk of relying on peer support alone is that the status quo may<br />

be maintained and alternative approaches or ways of understanding a situation may<br />

not be considered.<br />


More than other disciplines, nurses on inpatient units rotate shifts. This makes<br />

consistent attendance at group clinical supervision sessions more difficult. To<br />

accommodate their schedules, the group clinical supervision happens in open rather<br />

than closed sessions. This can have an impact on group cohesion when membership<br />

changes from session to session. Given the high turnover of clients on inpatient<br />

areas, the focus of the clinical supervision tends to change from session to session<br />


ather than staff being able to talk about particular clients over an extended period<br />

of time. One way of attending to this, particularly given the “revolving door” nature<br />

of hospital admissions, is to provide time to discuss clients who are re-admitted as<br />

an opportunity to learn from their previous stays. This underlines the importance of<br />

the clinical supervisor being flexible and available to address the issues that can arise<br />

on an inpatient unit spontaneously on a day-to-day basis. This is further discussed<br />

in Spontaneous <strong>Clinical</strong> <strong>Supervision</strong>: <strong>Clinical</strong> Supervisor as Lighthouse, p. 66.<br />

Nurses on inpatient units have 24-hour responsibility for their clients and no separate<br />

office space. On one unit they described feeling as though they are in a fish bowl,<br />

constantly being observed and accessible to clients in a way that other professionals<br />

are not. This makes boundary setting with clients more challenging. Nurses may feel<br />

powerless because they feel they have less control over their environment.<br />

Nurses usually see clients when the clients are in crisis. They are less likely than other<br />

members of the team to see clients at other stages in their lives such as when they are<br />

functioning in the community. Nurses attend to a broad range of clients’ needs that<br />

include physical as well as emotional needs, and are involved in tasks such as providing<br />

medication, restraining clients, caring for wounds and establishing a therapeutic<br />

relationship. This places nurses within the client’s personal space in ways that are<br />

quite different from other disciplines. This is an important difference for the clinical<br />

supervisor to consider.<br />


Nursing and <strong>Clinical</strong> <strong>Supervision</strong><br />

Since nursing staff may not be familiar with the process of clinical supervision, clinical<br />

supervisors should provide education up front about what clinical supervision is and<br />

is not in order to develop a “safe” environment where nurses are willing to disclose<br />

their practice challenges. The preparation includes:<br />

• acknowledging their unique position on the team and how that affects their<br />

client interactions<br />

• differentiating between the procedural activities that are the focus of<br />

administrative supervision<br />

• explaining the differences between therapy and clinical supervision to reinforce<br />

the respect for appropriate boundaries between the clinical supervisor and<br />

the nurse.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

The clinical supervisor explains that the focus is on the professional development<br />

of the nurse in the context of his or her work with the client, rather than on the<br />

development of action plans for the nurse’s personal problems. In other words, the<br />

focus is on the nurse’s process and behaviour with the client. The clinical supervisor<br />

explains that clinical supervision is an opportunity for nurses to turn what they<br />

know and feel into skillful action by paying deliberate attention to their experience,<br />

and critically analyzing feelings and observations. The intended outcome is a new<br />

perspective on a situation that they initially found puzzling or surprising.<br />

A Multi-Method Professional<br />

Development Approach in<br />

Daily Practice<br />



In order to support staff to practice new skills and reflect on how it will change clinical<br />

practice, staff members have needed supervision and coaching to increase their<br />

confidence and knowledge base to address concurrent disorders. One of the camh’s<br />

strategic directions focuses on providing integrated care to clients. Best practice literature<br />

suggests that program integration means:<br />

[M]ental health treatments and substance abuse treatments are<br />

brought together by the same clinicians/support workers, or team of<br />

clinicians/support workers, in the same program, to ensure that the<br />

individual receives a consistent explanation of illness/problems and a<br />

coherent prescription for treatment rather than a contradictory set of<br />

messages from different providers. (Health Canada, 2001, p. vii)<br />

Consequently, the clinical staff continues to develop skills to address how addictions<br />

and mental health impact each other when working with clients.<br />


A Multi-Method Professional Development Approach in Daily Practice<br />

Historically, clients were sent to specialized programs that separated mental health<br />

and addictions. In the Schizophrenia Program, many of the staff participated in<br />

trainings to address concurrent disorders. The staff has been working toward providing<br />

integrated care. While many staff members are addressing these issues regularly,<br />

some also express the concern that maybe “I could be doing more” as a clinician.<br />

W.R. Miller et al. (2006) note that “to learn any new behavioural skill, people need<br />

not only informational training but also:<br />

• clear and accurate feedback regarding their performance<br />

• guidance from a supervisor / coach who has greater expertise and proficiency in<br />

the skill.<br />

Without performance feedback, significant change in practitioner behaviour does<br />

not occur.” (W.R. Miller et al., 2006, p. 35) While trainings provide clinicians with a<br />

foundation around theory, there is a lack of confidence expressed by staff members<br />

in their ability to provide integrated treatment. They say that they need ongoing<br />

practice to develop skills in developing concurrent disorders treatment.<br />

Coaching/Partnering Style of <strong>Supervision</strong>—<br />

A Motivational Interviewing Approach<br />

An approach to clinical supervision has been used to help staff members develop<br />

their clinical skills around concurrent disorders. This approach involves coaching<br />

and gives clinicians an opportunity to work with the clients who are actively using<br />

substances. The clinical supervisor uses a motivational interviewing approach that<br />

promotes a coaching rather than instructional style. <strong>Clinical</strong> supervisors model and<br />

teach motivational interviewing approaches in the way that they work with the clinician,<br />

as well as the client. The coach communicates to the clinician that ambivalence<br />

is expected when clients are considering changing their substance use patterns, and<br />

that clients choose whether or not to make a change. Typically clinicians seek out<br />

this support from the supervisor when clients are in an early stage of treatment<br />

and may be starting to consider making a change in their substance use (e.g., the<br />

engagement or persuasion stage of treatment). These stages are defined by Mueser<br />

et al., 2003, pp. 123-124).<br />

During this process, the role of the clinical supervisor evolves from one of cofacilitator<br />

and role model to observer as the clinician develops the skills and confidence<br />

needed to provide integrated care. Initially, the clinical supervisor may be more<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

engaged with the client, but over time steps back. The supervisor role is explained to<br />

the client so that she or he knows that the primary relationship is with the clinician.<br />

The clinical supervisor and clinician usually contract that every four sessions they<br />

will evaluate and decide whether to re-contract to continue the process. The client<br />

is also consulted about the length of involvement to see if this matches his or her<br />

goal for treatment. The clinical supervisor asks for written evaluations from the<br />

clinician to assess the usefulness of this role. The clients have also been asked to fill<br />

out evaluations on their experiences. This approach has been used primarily for<br />

individual sessions.<br />

Group supervision<br />

When the clinical supervisor is involved in coaching/supervising staff in co-facilitating<br />

a group on concurrent disorders, the contract is usually for a longer time period.<br />

The focus in this setting is to help staff develop skills needed to work with clients<br />

presenting with concurrent disorders issues. Some clinicians may also need help with<br />

developing group facilitation skills. For example, a clinical supervisor and clinicians<br />

work together to develop a handbook that would guide the staff in facilitating sessions.<br />

The long-term goal for the clinical supervisor is to step back, observe and provide<br />

feedback until the clinicians decide they are ready to continue facilitating the group<br />

on their own. The clinical supervisor often becomes more of a clinical consultant as<br />

needed, rather than a supervisor or coach.<br />

Community of practice<br />

Beitler (2005) discusses the idea of a community of practice as a group of like-minded<br />

clinicians who are interested in exploring and developing skills in a specific practice<br />

area. He notes:<br />

The primary focus is the sharing of experiences and new ideas that<br />

members can use in practice. Key themes include a domain of common<br />

issues, developing a sense of community that includes trust and<br />

a social bond, and the element of practice. The majority of the members<br />

must be seasoned practitioners who are bringing their issues,<br />

ideas, advice and applying this knowledge to their practice, and then<br />

reporting back their experiences (pages 1, 7–8).<br />

(Beiter, M.A. (2005). “Strategic Organizational Learning.” Greensboro,<br />

NC: Practioner Press International. (pp. 70-77)).<br />


A Multi-Method Professional Development Approach in Daily Practice<br />

Beitler indicates that the co-ordinators do not have to be the leading experts in the<br />

field, but do need to be passionate about the knowledge domain and be well respected.<br />

One such project has been a pilot of a Motivational Interviewing Community of<br />

Practice. These sessions provide opportunities for people with more advanced training<br />

in motivational interviewing to practice skills through participation in role plays,<br />

watching videos and discussing challenges in their practice. This process of learning<br />

gives clinicians an opportunity to review best practice literature, learn from each<br />

other and practice skills. Peers take responsibility for the sessions. The early sessions<br />

have been organized and co-facilitated by a group of clinicians who are experienced<br />

in the area of motivational interviewing and have provided training in this area. This<br />

project is in its beginning phase. Initial evaluations have been positive. Clinicians<br />

are invited to participate in planning and continuing the developing of this learning<br />

initiative. In addition, a practice is being developed with staff members who are less<br />

experienced in motivational interviewing in the Schizophrenia Program. The staff<br />

are working to apply the recovery model and want to practice skills of motivational<br />

interviewing. Staff may have less experience with motivational interviewing, but would<br />

like to develop skills; share knowledge and challenges; and develop confidence in their<br />

practice. In the near future, as this project continues, there may be access to a listserv<br />

to help people share articles, discuss clinical challenges and network around motivational<br />

interviewing issues.<br />

Concurrent disorders journal club<br />

These journal clubs started out as a way to share best practices on integrated care.<br />

This learning is not clinical supervision but a way of sharing information based<br />

on readings from the book Treating Concurrent Disorder: A Guide for Counsellors<br />

(Skinner, 2005). This six-session group is held monthly and is facilitated by one or<br />

two staff members who specialize in concurrent disorders. Each month one of the<br />

authors comes to discuss his or her chapter. The meeting focuses on comments,<br />

thoughts, and questions related to the chapter (e.g., motivational interviewing, family<br />

issues, youth and setting up group programming). The clinicians are asked to evaluate<br />

this learning experience at the end of the cycle. Approximately 10 people are involved<br />

in each journal club.<br />

An advanced journal club has evolved in response to people’s participation and<br />

interest in further learning. In this group, guest speakers focus on a topic related to<br />

concurrent disorders best practices guidelines. Clinicians share clinical scenarios<br />

and request feedback. This format is continuing to evolve as the clinicians suggest<br />

learning ideas. As staff develop their skills and confidence in working with clients<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

that present with concurrent disorders issues, they are providing leadership in facilitating<br />

and organizing the journal clubs. As stated by Miller, et al. (2006), “a persistent<br />

novice golfer on a driving range can gradually learn how to drive a ball farther, but<br />

learning can be substantially accelerated by a little coaching from an experienced<br />

professional” (pp. 35-36).<br />

Ethical Considerations in<br />

<strong>Clinical</strong> <strong>Supervision</strong><br />

Because the clinical practice environment is becoming more complex, clinicians are<br />

bringing clinical scenarios to supervision sessions that defy neat and tidy resolutions,<br />

thus challenging clinical supervisors to tread ethical paths they may have never<br />

encountered in their own front-line careers. For this reason, a new emphasis has been<br />

placed on the importance of ethics training for all clinical supervisors, no matter how<br />

much clinical experience they have to inform their work with clinicians.<br />

Frederic Reamer, a professor of social work in the United States, has done extensive<br />

work on ethical considerations in clinical practice and supervision (Reamer, 1994,<br />

1999, 2001, 2003). He emphasizes that it is crucial for clinical supervisors to have<br />

the skills and background necessary to develop in their clinicians a way of thinking<br />

ethically, since it is not possible to have hard and fast rules about many of the dilemmas<br />

encountered in clinical practice. This way of thinking involves ethical decision-making,<br />

which takes into account conflicting values and duties, identifies individuals and<br />

groups likely to be affected by a certain decision, and tentatively identifies all possible<br />

courses of action with possible risks and benefits. In addition, Dr. Reamer’s approach<br />

examines reasons for and against each possible course of action. He recommends<br />

that ethical theories, principles and guidelines; codes of ethics; legal principles;<br />

discipline-specific practice theory and principles; personal values; and agency policies<br />

and regulations all be used to inform the examination.<br />

In a 14-week graduate social work course at Rhode Island College, Dr. Reamer<br />

covers a wide range of “key risk areas,” which he maintains are taken into account<br />

by good quality clinical supervision. The areas include:<br />


• client rights<br />

• confidentiality and privacy<br />

• informed consent<br />

• service delivery<br />

• boundary issues and conflicts of interest<br />

• documentation<br />

• defamation of character<br />

• client records<br />

• supervision<br />

• staff development and training<br />

• consultation<br />

• client referral<br />

• fraud<br />

• termination of services and client abandonment<br />

• practitioner impairment<br />

• evaluation and research.<br />


Ethical Considerations in <strong>Clinical</strong> <strong>Supervision</strong><br />

Dr. Reamer points to the principle of “standard of care,” which he defines as “what<br />

an ordinary, reasonable, and prudent professional, with the same or similar training,<br />

would have done under the same or similar circumstances.” He considers this the<br />

most important sentence in clinical supervision. It can guide discussion of complex<br />

clinical dilemmas. Dr. Reamer cites two types of standards of care.<br />

• A “substantive” standard of care is one that is widely accepted across clinical<br />

practice settings, for instance, the norm that dating clients is indefensible on<br />

ethical grounds.<br />

• “Procedural” standards of care cover processes that are invoked with difficult,<br />

ethically complex scenarios—cases in which experienced clinicians and practice<br />

leaders commonly disagree about what constitutes the best course of action.<br />

Activities that encompass procedural standards of care include consulting with<br />

colleagues and supervisors; reviewing relevant ethical standards; reviewing relevant<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

laws, policies and regulations; reviewing relevant literature; obtaining legal consultation<br />

when necessary; consulting an ethics committee, if available; and documenting<br />

decision-making steps.<br />


It is beyond the scope of this guide to cover the depth and breadth of what ethical<br />

training clinical supervisors require. However, it may be helpful to consider a common<br />

clinical issue in which ethical considerations figure prominently. Client discharge<br />

or termination provides a good example. In many instances, clinicians may struggle<br />

with decisions to discharge a client before he or she has completed a treatment<br />

program. This struggle may involve weighing the circumstances that precipitated the<br />

potential discharge against an appreciation of the client’s significant ongoing needs.<br />

If the decision to discharge is carried out, Dr. Reamer recommends the following<br />

guidelines to protect clients and minimize risk:<br />

• Provide clients with names, addresses and telephone numbers of at least three<br />

appropriate referrals.<br />

• Follow up with a client who has been terminated. If the client does not go to<br />

the referral, write a letter to him or her about relevant risks.<br />

• Provide as much advance warning of the termination as possible.<br />

• When clients announce their decision to terminate prematurely, explain the<br />

risks involved and suggestions for alternative care. Include this information<br />

in a follow-up letter.<br />

• Carefully document in the case record all decisions and actions related to<br />

termination.<br />

• In cases involving discharge from residential facilities, prepare a comprehensive<br />

discharge plan and, with client consent, notify significant others.<br />

• Provide clients with clear instructions to follow in the event of an emergency.<br />

Ask clients to sign a copy acknowledging that they have received the instructions<br />

and that the instructions were explained to them.<br />

• Consult with colleagues and supervisors about termination strategy and decisions.<br />

• Consult relevant code of ethics standards.<br />


Evaluating <strong>Clinical</strong> <strong>Supervision</strong><br />

Although clinical supervision is regarded as an important factor in enhancing client<br />

outcome in mental health and other human service settings, there is limited research<br />

support for the effectiveness of clinical supervision (Strong et al., 2003). In particular,<br />

there has been a call for research in the following areas:<br />

• evaluating supervisory training<br />

Evaluating <strong>Clinical</strong> <strong>Supervision</strong><br />

• examining diversity issues in clinical supervisor-clinician relationships and in<br />

various service settings<br />

• exploring the impact of clinical supervision on client outcomes (Bruce & Austin,<br />

2000).<br />

Some recent exploratory research addresses key areas related to evaluating the clinical<br />

supervision context and supervisor skills. Areas that have been addressed include:<br />

• core competencies in supervision (Falender et. al., 2004)<br />

• diversity / cultural competence in supervisors (Armour et al., 2004)<br />

• benefits and barriers to effective clinical supervision (Strong et al., 2003)<br />

• trainee preferences in clinical supervisor feedback (both positive and negative)<br />

(Heckman-Stone, 2003).<br />

This section will summarize these findings and will provide a number of concrete<br />

suggestions for evaluation approaches and tools that can be used in clinical supervision.<br />

The section will conclude with a brief discussion of the importance of documenting<br />

supervision in clinical settings—an area that has been identified as being of key legal<br />

and ethical importance (Falvey & Cohen, 2003). Note that performance evaluation<br />

of clinicians is not addressed in this section, as it falls outside of the purview of<br />

clinical supervision camh, and is already carried out annually using approved<br />

protocols and tools.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Core Competencies in<br />

<strong>Clinical</strong> <strong>Supervision</strong><br />

Falender and colleagues (2004) recently published a consensus statement on core<br />

competencies in psychology supervision. This was done in response to recommendations<br />

arising from an international working conference held in 2002. The primary<br />

aim was to identify areas of consensus and difference in a variety of research and<br />

practice domains, including clinical supervision. (For more information about conference<br />

topics and membership, see Falendar et al., p. 773.) Falender and colleagues<br />

note that identifying competencies helps move professions from normative (or subjective)<br />

assessments to criterion-based (or objective) assessments. This approach has<br />

the advantage of introducing greater rigour to the clinical supervision process as well<br />

as to the performance and techniques of individual supervisors. A brief overview of<br />

these core competencies sets the stage for a discussion of what we might evaluate in<br />

clinical supervision, and how this can be best carried out.<br />

Although the competencies outlined below were developed in reference to the<br />

discipline of psychology, they are broadly applicable and relevant to other clinically<br />

focused disciplines such as social work, nursing, medicine, psychiatry, occupational<br />

and recreation therapy. <strong>Clinical</strong> supervisor competencies have been divided into six<br />

general categories, with a number of micro-skills within each area. The broad competencies<br />

of knowledge, skills, values, social context / overarching issues, training<br />

and assessment are summarized in Table 1. The final area, assessment, is particularly<br />

relevant to evaluation of clinical supervision. Note that the wording of the discrete<br />

micro skills has been somewhat adapted to better reflect clinical practice at camh.<br />



1. <strong>Knowledge</strong> • <strong>Knowledge</strong> of area being supervised<br />

• <strong>Knowledge</strong> of relevant models, theories, interventions and<br />

research<br />

• <strong>Knowledge</strong> about clinicians’<br />

• Learning and professional development<br />

• <strong>Knowledge</strong> of ethical and legal issues relating to supervision<br />



Core Competencies in <strong>Clinical</strong> <strong>Supervision</strong><br />

• <strong>Knowledge</strong> of clinical outcome and process evaluation<br />

• <strong>Knowledge</strong> and awareness of diversity, marginalization and<br />

oppression issues and diversity competence<br />

2. Skills • <strong>Supervision</strong> methods<br />

• Relationship skills (building a supervisory alliance)<br />

• Sensitivity to multiple roles with supervisee and able to balance<br />

multiple roles<br />

• Ability to provide constructive and effective feedback<br />

• Ability to promote supervisee self-assessment and growth<br />

• Ability to conduct own self-assessment process<br />

• Ability to assess supervisee’s learning needs and developmental<br />

level<br />

• Ability to encourage and use evaluative feedback from<br />

supervisees<br />

• Teaching skills<br />

• Ability to set appropriate boundaries and seek consultation/<br />

supervision (assess own competence)<br />

• Flexibility<br />

• Integrating and presenting evidence-based practice and<br />

best practice principles<br />

• Documentation procedures<br />

• Ability to impart evidence-based practice knowledge within<br />

the supervisory session<br />

3. Values • Supervisor is accountable for supervision provided—to<br />

supervisee and to client<br />

• Respectful<br />

• Responsible for diversity awareness and competence<br />

• Balance between support and constructive feedback/<br />

challenging<br />

• Empowering<br />

• Commitment to continuous learning and professional growth<br />

• Balance between clinical and training needs<br />

• Valuing ethical principles<br />

• Knowing and using supervision research and best practices<br />

• Committed to knowing own limitations<br />



4. Social context / • Diversity<br />

overarching • Ethical and legal issues<br />

issues • Developmental process<br />

• <strong>Knowledge</strong> of organization and expectations re. clinical<br />

supervision<br />

• Awareness of socio-political context within which supervision<br />

is conducted<br />

• Creation of climate in which authentic, honest feedback is<br />

the norm (both supportive and challenging feedback)<br />

5. Training in • Continuing education in supervision knowledge and skills<br />

supervision • Receives supervision of supervision, including observation<br />

competencies (videotape/audiotape/in vivo observation with critical<br />

feedback)<br />

6. Assessment of • Successful completion of supervision course / workshop<br />

supervision • Documented evidence of supervision of supervision, noting<br />

competencies readiness to supervise independently<br />

• Evidence of direct observation<br />

• Documented evidence of supervisory experience reflecting<br />

diversity competence<br />

• Documented supervisee feedback<br />

• Self-assessment and awareness of need for<br />

consultation / supervision when necessary<br />

• Assessment of supervision outcomes<br />

• Impact of client outcomes<br />

Adapted from Falender et al., 2004, p778<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Based on the micro-skills outlined in competency number six, assessment of<br />

supervisor competencies, evaluation of clinical supervision should ideally incorporate<br />

the following elements:<br />

• Certificate of completion of some form of continuing professional education<br />

(e.g., course, workshop) in clinical supervision<br />

• Documentation that the supervisor has had supervision that focuses on his or her<br />

role as supervisor, and recommendations (with follow-up and development plan)<br />


Core Competencies in <strong>Clinical</strong> <strong>Supervision</strong><br />

• <strong>Clinical</strong> supervisor self-assessment (reflective practice) (e.g., through attendance<br />

in a supervisors’ supervision group, or through openness to learning from and<br />

implementing evaluation feedback by supervisees)<br />

• Evidence of diversity competence (e.g., completion of camh diversity training,<br />

other measures of diversity / cultural competence, which can be used with both<br />

supervisor and supervisees)<br />

• <strong>Clinical</strong> supervisor evaluation (completed by clinicians)—both process and<br />

outcome (e.g., using the <strong>Supervision</strong> Feedback Scale (Heckman-Stone, 2003),<br />

discussed on page XX in this section)<br />

• Link to client outcomes—possibly via the Interdisciplinary Plan of Client Care<br />

(ipcc) if possible.<br />



In order to better understand the clinical supervision context, its strengths and areas<br />

for improvement, Strong and colleagues used focus groups and brief interviews to<br />

explore clinical supervision practice among allied health professionals in a large<br />

mental health service. The focus group questions, which closely mirrored the questions<br />

used in the brief interviews, can provide a useful, semi-structured guide for<br />

carrying out periodic process evaluations of clinical supervision groups. The questions<br />

asked included:<br />

• What do you see as the benefits of supervision?<br />

• What would you regard as ideal supervision in your profession?<br />

• What do you see as the best aspects of current supervision practices in your<br />

employing organization?<br />

• In what ways is current supervision less than ideal?<br />

• What are the main barriers to good supervision in mental health service?<br />

• What issues have been raised by your experiences with cross-professional<br />

supervision?<br />

• What are the three most important things that need to be done to improve<br />

supervision practice? (Strong, et al., 2003, p. 195)<br />


If a culture of authenticity and honesty is fostered in clinical supervision groups,<br />

periodically reflecting on the process of clinical supervision can lead to valuable<br />

insights and enhanced effectiveness of the supervisors. The research found that clinical<br />

supervision was a key to improving clinical competence and implementation of best<br />

practices, as well as a source of support for staff. The main barriers identified were<br />

the absence of a clear organizational policy on clinical supervision and failure to<br />

allocate sufficient resources to support clinical supervision practice. Articulating a<br />

model of clinical supervision and a training agenda were also seen as primary issues.<br />

It may be interesting and illuminating to compare the experiences and perceptions<br />

of camh clinicians with the findings of Strong and his colleagues (2003).<br />



The issue of diversity competence has been identified as being of key importance in<br />

clinical supervision, and is reflected in a number of the core micro-skills of clinical<br />

supervisor competencies noted above. As Divac and Heaphy (2005) point out,<br />

“developing cultural competence is now a requirement for achieving appropriate<br />

professional standards in therapy and supervision training” (p.282). Diversity is a<br />

factor not only in working with clients, but in the heterogeneity of supervision groups<br />

and dyads as well. Thus, diversity competence is relevant in clinical supervisors’<br />

feedback around case formulation and intervention, and in power dynamics, experiences<br />

of privilege/oppression/marginalization, and working across difference in the<br />

clinical supervision context. There is a small but growing literature focused on the<br />

development, application and evaluation of diversity / cultural competence in clinical<br />

supervisors (Armour et al., 2004; Constantine et al., 2005; Divac & Heaphy, 2005).<br />

Evaluation tools<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

A number of tools have been developed and validated for use by instructors, clinical<br />

supervisors and/or clinicians. These range from brief process evaluations to more<br />

extensive summary evaluations. These tools may help clinical supervisors to assess<br />

their own competence in this area.<br />

Armour et al. used a closed-ended, 13-item, self-administered questionnaire and<br />

anonymously written responses to five reflecting questions in a repeated measures<br />

design. (A copy of the closed-ended questionnaire is included in Armour et al.’s<br />


Core Competencies in <strong>Clinical</strong> <strong>Supervision</strong><br />

article as an appendix, p. 38.) Both clinical supervisors and clinical supervision<br />

groups could use this tool to periodically assess progress in diversity competence,<br />

and to stimulate discussion about areas for professional and personal growth.<br />

The questionnaire addressed comfort with diversity; awareness of issues of power,<br />

control and interpersonal conflict; and knowledge about oppressed groups. The<br />

added open-ended reflecting questions included:<br />

• highlights in practitioners’ diversity training experiences<br />

• peak enjoyable or disturbing experiences (or both) in diversity training<br />

• an idea or skill supervisors could use with supervisees<br />

• how supervisors’ insights (facilitated by their responses to previous questions)<br />

could contribute to their effectiveness in supervision<br />

• actions that supervisors could take to enhance the cultural competence in their<br />

agency or program. (Armour et al., 2004, p. 34)<br />

The study showed significant gains in diversity awareness in the period between the<br />

end of the training and follow-up. <strong>Clinical</strong> supervisors also noted areas for further<br />

development in improving supervision practice, including normalizing discomfort,<br />

awareness of retreating from exploring diversity, and permission to address “socially<br />

taboo” topics.<br />

Divac and Heaphy (2005) suggest that ongoing feedback and reflection in supervision<br />

of supervision sessions is an important formative evaluation strategy for diversity<br />

competence. They also suggest that semi-structured interviews with trainee supervisors<br />

should be carried out at the end of the academic year. (The content of the interviews<br />

was not yet developed by the authors at the time of publication of their article.)<br />

Divac and Heaphy describe the content and format of monthly sessions for clinical<br />

supervisors, where the specific focus was on fostering diversity competence. This<br />

approach may be of particular relevance to the professional development of clinical<br />

supervisors due to its richness in process and experiential emphasis. In this model,<br />

trainee supervisors meet one day per month to discuss key issues, skills and abilities<br />

in cross-cultural practice. Divac and Heaphy note that the main focus is on the<br />

process and experience of engaging with subjective assumptions, biases and experience<br />

related to their own and others’ cultures. In addition, trainees use the group format<br />

to reflect on diverse aspects of their identities, which may be privileged in some<br />

contexts and disadvantaged in others. Finally, group sessions are videotaped and<br />

reviewed to encourage continued reflection and exploration of issues.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

In another study, Constantine, Warren and Miville (2005) present and discuss the use<br />

of the multicultural case conceptualization ability exercise, a tool and coding system<br />

used to determine the extent to which clinicians are able to integrate salient cultural<br />

issues into two different conceptualizations of a client case.<br />

Finally, Pope-Davis and colleagues (2000) describe the development and validation<br />

of the Multicultural Environmental Inventory—an instrument designed to measure<br />

the degree to which graduate counselling programs address multicultural issues in<br />

their curricula, clinical supervision, climate and research. The instrument was condensed<br />

from 53 to 27 items based on the results of factor analyses, and showed promise<br />

in its ability to assess change over time, as well as good validity and reliability. Although<br />

designed for academic settings, it may be useful to test either the instrument as a whole,<br />

or the supervision subscale, as a way to evaluate clinical supervisors’ effectiveness in<br />

addressing and promoting cultural competence in clinical supervision groups.<br />

Cultural and diversity competence is now being addressed in a more rigorous fashion<br />

in clinical supervision settings. This reflects a growing awareness of their importance,<br />

and of the need for ways to assess and identify gaps in knowledge and skills (both in<br />

clinical supervisors and in front-line clinicians).<br />


Providing and accepting clear and concrete feedback, identifying strengths and areas<br />

for improvement, and specific concerns with respect to good clinical care can be<br />

difficult for both clinical supervisor and clinician. Yet “when supervisees reflect on<br />

their supervision, what comes to mind most often is the quality and quantity of<br />

feedback they received” (Bernard & Goodyear, 1998). Therefore, clinical supervisors<br />

need to evaluate the extent to which they are providing constructive and salient<br />

feedback to clinicians.<br />

Heckman-Stone (2003) carried out a pilot study with 40 graduate students from<br />

three training programs (counselling psychology, clinical psychology and masters<br />

degree in counselling). She used a scale of 10 items rated on a seven-point, Likert-type<br />

scale, where 1= strongly disagree, 4 = neutral, and 7 = strongly agree. In addition,<br />

the author included four open-ended items designed to elicit examples of positive<br />

and negative feedback in clinical supervision, and the characteristics of good<br />

and poor use of feedback and evaluation by clinical supervisors. An example of<br />

the instrument, adapted for use with more experienced clinicians—as opposed to<br />


students—is presented below. Based on the results of the pilot study, Heckman-<br />

Stone outlines a number of recommendations in providing feedback to clinicians.<br />

These include:<br />

• Begin by describing the process of supervision.<br />

• Set clear, mutually agreed upon performance criteria.<br />

• Reliably observe the supervisee’s work.<br />

• Compare the observations with performance objectives/criteria.<br />

• Have supervisee provide a self-evaluation first.<br />

• Start with positive evaluations.<br />

Core Competencies in <strong>Clinical</strong> <strong>Supervision</strong><br />

• Specify the skill area being addressed in giving the feedback.<br />

• Have supervisees set the agenda for supervision sessions as much as possible.<br />

• Monitor supervisees’ use of feedback and evaluation.<br />

The <strong>Clinical</strong> <strong>Supervision</strong> Feedback Scale can be used as either a process or outcome<br />

evaluation for clinical supervisors to assess their skills in providing feedback, and<br />

identify areas for development. Another structured clinical supervision evaluation<br />

instrument, the Group Supervisory Behavior Scale (gsbs, White and Rudolph, 2000)<br />

has also been demonstrated to have good reliability and validity, and may be useful<br />

in evaluating supervisor behaviours in group supervision contexts.<br />



1. My supervisor welcomed comments about his or her<br />

style as a supervisor.<br />

1 2 3 4 5 6 7<br />

2. My supervisor’s comments about my work<br />

were understandable.<br />

1 2 3 4 5 6 7<br />

3. I didn’t receive timely information about how<br />

I was doing as a therapist. [reverse scored]<br />

1 2 3 4 5 6 7<br />

4. I have had written feedback from my supervisor<br />

about my clinical work.<br />

1 2 3 4 5 6 7<br />

5. My supervisor balanced his or her feedback<br />

between positive and negative statements.<br />

1 2 3 4 5 6 7<br />


6. The feedback I received from my supervisor<br />

was based on his or her direct observation of my work<br />

(including video / audiotapes).<br />

1 2 3 4 5 6 7<br />

7. The feedback I received was directly related to<br />

the goals I set in supervision.<br />

1 2 3 4 5 6 7<br />

8. There were inconsistencies between my supervisor’s<br />

feedback to me in session and written feedback.<br />

[reverse scored]<br />

1 2 3 4 5 6 7<br />

9. I am satisfied with my supervisor’s use of feedback<br />

in session.<br />

1 2 3 4 5 6 7<br />

10. I am satisfied with my supervisor’s written feedback. 1 2 3 4 5 6 7<br />

Open-ended items:<br />

11. Please describe a positive experience you have had<br />

with feedback in supervision.<br />

1 2 3 4 5 6 7<br />

12. Please describe a negative experience you have had<br />

with feedback in supervision.<br />

1 2 3 4 5 6 7<br />

13. Please list characteristics of good use of feedback<br />

by your supervisor.<br />

1 2 3 4 5 6 7<br />

14. Please list characteristics of poor use of feedback<br />

by your supervisor.<br />

1 2 3 4 5 6 7<br />

Adapted from Heckman-Stone, 2003, p.28.<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />



The importance of documentation in clinical supervision cannot be overstated, and<br />

is an important source of evaluative feedback to clinicians. As Falvey and Cohen state:<br />

Keeping records is standard practice for virtually all human services<br />

and medical disciplines. From a legal as well as an ethical perspective,<br />

if it isn’t documented, it didn’t occur. The question for supervisors,<br />

then, is not whether to document, but how to do so in an efficient<br />

manner. (Falvey et al., 2003, p. 77)<br />


The authors note that over-documentation can be as much an issue as under-documentation,<br />

and suggest the use of structured forms to capture case review data and<br />

recommendations. Falvey et al. also strongly recommend that clinicians not be given<br />

sole discretion in selecting cases for review in clinical supervision. They note that<br />

clinicians may not recognize important practice issues in all cases, and that significant<br />

client care problems or issues may not be addressed unless all cases are periodically<br />

reviewed. As the authors state:<br />

Leaving the choice of which cases to review up to the supervisee, while<br />

commonplace, is not an ethically or legally viable supervisory practice.<br />

Evaluation anxiety, concern over clinical errors or boundary violations,<br />

negative reactions to the supervisor, or failure to recognize the<br />

importance of clinical signs and symptoms contribute to a high rate<br />

of supervisee nondisclosure. (Falvey et al., 2003, p. 72)<br />

Falvey and Cohen also highlight the importance of a clinical supervision contract,<br />

records of all clinical supervision sessions (with details on cases discussed and<br />

decisions made); notes on cancelled or missed supervision meetings, and on significant<br />

conflicts in clinical supervision sessions and how they were handled. These documents<br />

can assist in identifying training/professional development needs, and provide<br />

“evidence of competent supervision should a supervisee grievance or client lawsuit<br />

subsequently arise” (Falvey & Cohen, 2003, p.68). They present samples of forms<br />

developed as part of a clinical supervision process evaluation/tracking package, titled<br />

the Focused Risk Management <strong>Supervision</strong> System (FoRMSS). (The authors provide<br />

sample forms in their article; see pages 73, 74 and 76.) These forms (or FoRMSS) can<br />

be adapted for use in clinical supervision groups as a way of maintaining a record of<br />

case discussions and a process evaluation of clinical supervision issues and outcomes.<br />

Conclusion<br />

Core Competencies in <strong>Clinical</strong> <strong>Supervision</strong><br />

Evaluation of clinical supervision is a complex and challenging task. However, it<br />

is crucial to fostering transparency, accountability and modelling of best practices.<br />

Areas for further research identified in the literature include evaluating/assessing<br />

clinical supervisors’ diversity competence, and demonstrating the impact of clinical<br />

supervision on client care outcomes. The latter may be facilitated by more active use<br />

of the Interdisciplinary Plan of Client Care (ipcc) in clinical supervision sessions,<br />

where ipcc goals and outcomes are routinely discussed as part of the case review<br />

and clinical feedback process. In the absence of clear and unequivocal empirical<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

support for best practice tools in clinical supervision assessment and evaluation,<br />

these preliminary instruments and scales should be regarded as a starting point in<br />

introducing greater rigour and accountability into the clinical supervision context.<br />


Available in pdf and Word versions on Insite:<br />

http://insite.camh.net/forms/clinical_forms/10258_interdisciplinary_plan_of_client_care.html<br />


References<br />

References<br />

Allison, K.W., Echemendia, R.J., Crawford, I. & Robinson, W.L. (1996). Predicting cultural competence:<br />

Implications for practice and training. Professional Psychology: Research and Practice, 27, 386–393.<br />

Armour, M.P., Bain, B. & Rubio, R. (2004). An evaluation study of diversity training for field instructors:<br />

A collaborative approach to enhancing cultural competence. Journal of Social Work Education, 40 (1),<br />

27–38.<br />

Baird, B.N. (1999). The Internship, Practicum, and Field Experience Placement <strong>Handbook</strong>: A Guide for the<br />

Helping Professions (2nd ed.). Upper Saddle River, NJ: Prentice Hall.<br />

Beitler, M.A. (2005). Strategic Organizational Learning. Greensboro, NC: Practitioner Press International.<br />

Bogo, M., Globerman, J. & Sussman, T. (2004a). Field instructor competence in group supervision:<br />

Students’ views. Journal of Teaching in Social Work, 24 (1/2), 199–216.<br />

Bogo, M. Globerman, J. & Sussman, T. (2004b). The field instructor as group worker: Managing trust<br />

and competition in group supervision. Journal of Social Work Education, 40 (1), 13–26.<br />

Bogo, M., & Vayda, E. (1998). The Practice of Field Instruction in Social Work: Theory and Process (2nd ed.).<br />

Toronto: University of Toronto Press.<br />

Bruce, E.J. & Austin, M.J. (2000). Social work supervision: Assessing the past and mapping the future.<br />

The <strong>Clinical</strong> Supervisor, 19 (2), 85–107.<br />

Butterworth, T. et al. (1997). It is Good to Talk: An Evaluation Study in England and Scotland.<br />

School of Nursing, Midwifery and Health Visiting, University of Manchester.<br />

Cashwell, C., Looby, E. & Houseley, W. Appreciating cultural diversity through clinical supervision.<br />

The <strong>Clinical</strong> Supervisor, 15 (1), 75–85.<br />

CDC National Prevention Information Network (no date). Cultural Competence. Available<br />

www.cdcnpin.org/scripts/population/culture.asp. Accessed: February, 2008.<br />

Centre for Substance Abuse Treatment (2007). Competencies for Substance Abuse Treatment <strong>Clinical</strong><br />

Supervisors. Technical Assistance Publication (TAP) Series 21–A. DHHS Publication No. (SMA) 07–4243.<br />

Rockville, MD: Substance Abuse and Mental Health Services Administration.<br />

College of Nurses of Ontario (2003). Guide to Nurses for Providing Culturally Sensitive Care. Toronto:<br />

Author.<br />

Constantine, M.G., Warren, A.K. & Mibille, M.L. (2005). White racial identity dyadic interactions in<br />

supervision: Implications for supervisees’ multicultural counseling competence. Journal of Counseling<br />

Psychology, 52 (4), 490–496.<br />

Cross, T., Bazron, D. & Issacs, M. (1989). Towards a Culturally Competent System of Care. Washington,<br />

DC: Georgetown University Child Development Center.<br />

Cutcliffe, J.R. & Lowe, L. (2005). A comparison of North American and European conceptualizations of<br />

clinical supervision. Issues in Mental Health Nursing, 26, 475–488.<br />

Cutcliffe, J. & Proctor, B. (1988). An alternative training approach to clinical supervision: Parts 1 and 2.<br />

British Journal of Nursing, 7 (5), 280–285; 7 (6), 344–349.<br />

D’Andrea, M. & Daniels, J. (1997). Multicultural counseling supervision: Central issues, theoretical<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

considerations, and practical strategies. In D.B. Pope Davis & H.L.K. Coleman (Eds.), Multicultural<br />

Counseling Competencies: Assessment, Education and Training, and <strong>Supervision</strong> (pp. 290–309). Thousand<br />

Oaks, CA: Sage.<br />

Divac, A. & Heaphy, G. (2005). Space for GRRAACCES training for cultural competence in supervision,<br />

Journal of Family Therapy, 27, 280–284<br />

Diversity Programs Office. (2003, May). Cultural Competence in <strong>Clinical</strong> Care: A <strong>CAMH</strong> Operating<br />

Framework. A Draft Discussion Document. Toronto: Centre for Addiction and Mental Health.<br />

Epling, M. & Cassedy, P. (2001). <strong>Clinical</strong> supervision: Visions from the classroom. In J.R. Cutcliffe, T.<br />

Butterworth & B. Proctor (Eds.), Fundamental Themes in <strong>Clinical</strong> <strong>Supervision</strong>. London, UK: Routledge.<br />

Falender, C. (2006). “You Said What”: Becoming a Better Supervisor [Online serial]. Available:<br />

www.continuingedcourses.net/active/courses/course024.php. Accessed: February 2008.<br />

Falender, C.A., Erickson Cornish, J.A., Goodyear, R., Hatcher, R., Kaslow, N.J., Levanthal, G. et al. (2004).<br />

Defining competencies in psychology supervision: A consensus statement. Journal of <strong>Clinical</strong><br />

Psychology, 60 (7), 771–785.<br />

Falvey, J.E. & Cohen, C.R. (2003). The buck stops here: Documenting clinical supervision. The <strong>Clinical</strong><br />

Supervisor, 22 (2), 63–80.<br />

Gallop, R. (2004). Providing clinical supervision. A workshop for advanced practice nurses and clinicians at<br />

the Centre for Addiction and Mental Health, Toronto.<br />

Garrett, M.T., Borders, L.D., Crutchfield, L.B., Torres-Rivera, E., Brotherton, D. & Curtis, R. (2001).<br />

Multicultural supervision: A paradigm of cultural responsiveness for supervisors. Journal of<br />

Multicultural Counseling and Development, 29, 147–158.<br />

Grey, A. & Fiscalini, J. (1987). Parallel process as transference-countertransference interaction.<br />

Psychoanalytic Psychology, 4 (2), 131–144.<br />

Haines A. & Donald A. (1998). Introduction. In A. Haines & A. Donald (Eds.), Getting Research Findings<br />

into Practice (pp. 1–9). London, UK: BMJ Publishing Group.<br />

Haarmans, M. (2004). A Review of <strong>Clinical</strong> Cultural Competence: Definitions, Key Components, Standards<br />

and Selected Trainings. Toronto: Centre for Addiction and Mental Health.<br />

Heckman-Stone, C. (2003). Trainee preferences for feedback and evaluation in clinical supervision. The<br />

<strong>Clinical</strong> Supervisor, 22 (1), 21–33.<br />

Health Canada (2001). Best Practices: Concurrent Mental Health and Substance Use Disorders. Ottawa, ON.<br />

Hernandez, P. (2003). The cultural context model in supervision: An illustration. Journal of Feminist<br />

Family Therapy, 15 (4), 1–18.<br />

Johnson, S.D. (1987). Knowing that versus knowing how: Toward achieving expertise through multicultural<br />

training for counselors. The Counseling Psychologist, 15, 320–331.<br />

Kadushin, A. (1976). <strong>Supervision</strong> in Social Work. New York, NY: Columbia University Press.<br />

Kadushin, A. & Harkness, D. (2002). <strong>Supervision</strong> in Social Work (4th ed.). New York, NY: Columbia<br />

University Press.<br />


References<br />

Kerner, J., Rimer, B. & Emmons, K. Dissemination research and research dissemination: How Can We<br />

Close the Gap? Health Psychology, 24 (5), 443–446.<br />

Kolb, D.A. (1984). Experiential Learning: Experience as the Source of Learning and Development.<br />

Englewood Cliffs, NJ: Prentice Hall.<br />

Leong, F.T.L. & Wagner, N.S. (1994). Cross cultural counseling supervision: What do we know? What do<br />

we need to know? Counselor Education And <strong>Supervision</strong>, 34, 117–131.<br />

Lo, H.T. & Fung, K. (2003). Culturally competent psychotherapy. Canadian Journal of Psychiatry, 48, 161–170.<br />

Lybarger, J. S. (2001). Inclusive <strong>Clinical</strong> <strong>Supervision</strong>. [Online course]. Available:<br />

www.homesteadschools.com/LCSW/courses/Inclusive%20<strong>Clinical</strong>%20<strong>Supervision</strong>. Accessed: February<br />

2008.<br />

Mackenzie, R. (1990). Time-limited Group Psychotherapy. Washington, DC: American Psychiatric Press, Inc.<br />

Magnuson, S., Norem, K., Jones, N.K., McCrary, J.C. & Gentry, J. (2000). The triad as a cross-cultural<br />

training intervention for supervisors. The <strong>Clinical</strong> Supervisor, 19 (2), 197–210.<br />

Miller, W.R. et al. (2006). Disseminating evidence-based practices in substance abuse treatment: A review<br />

with suggestions. Journal of Substance Abuse Treatment, 31, 25–39. (last update July 21, 2007)<br />

Mueser, K.T. et al. (2003). Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York:<br />

Guilford Press.<br />

Okun, B.F., Fried, J. & Okun, M.L. (1999). Understanding diversity: A learning-as-practice primer. Pacific<br />

Grove, CA: Brooks/Cole.<br />

Paniagua, F.A. (1998). Assessing and Treating Culturally Diverse Clients: A Practical Guide (2nd ed.).<br />

Thousand<br />

Oaks, CA: Sage.<br />

Pedersen, P. (2000). A <strong>Handbook</strong> for Developing Multicultural Awareness (3rd ed.). Alexandria, VA:<br />

American Counseling Association.<br />

Petr, C.G. & Walker, U. (2005). Best practices inquiry: A multi-dimensional, value-critical framework.<br />

Journal of Social Work Education, 41 (2), 251–267.<br />

Pope-Davis, D.B., Liu, W.M., Nivitt, J. & Toporek, R.L. (2000). The development and initial evaluation of<br />

the Multicultural Environmental Inventory: A preliminary investigation. Cultural Diversity and Ethnic<br />

Minority Psychology, 6 (1), 57–64.<br />

Proctor, B. (1991). On being a trainer. In W. Dryden & B. Thorne (Eds.), Training and <strong>Supervision</strong> for<br />

Counselling in Action (pp. 49–73). London, UK: Sage.<br />

Proctor, B. (1986). <strong>Supervision</strong>: A co-operative exercise in accountability. In M. Marken & Payne (Eds.),<br />

Enabling and Ensuring. Leicester: National Youth Bureau and Council for Education and Training in<br />

Youth and Community Work.<br />

Reamer, F. (2001). Tangled Relationships: Managing Boundary Issues in the Human Services. New York, NY:<br />

Columbia University Press.<br />

Reamer, F.G. (1994). Social work values and ethics. In F.G. Reamer (Ed.), The Foundations of Social Work<br />

<strong>Knowledge</strong> (pp. 195–230). New York, NY: Columbia University Press.<br />

Reamer, F G. (1999). Social Work Values and Ethics (2nd ed.). New York: Columbia University Press.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Reamer, F.G. (2003). Boundary issues in social work: Managing dual relationships. Social Work, 48 (1),<br />

121–133.<br />

Registered Nurses Association of Ontario (2002). Establishing Therapeutic Relationships. Nursing Best<br />

Practice Guidelines, Toronto: Author.<br />

Renner, P. (1999). The Art of Teaching Adults: How to Become an Exceptional Instructor and Facilitator.<br />

Vancouver, BC: Training Associates.<br />

Rogers, E. (1983). Diffusion of Innovations, 3rd Ed. New York: Free Press.<br />

Skinner, W. (2005). Treating Concurrent Disorders: A Guide for Counsellors. Toronto: Centre for Addiction<br />

and Mental Health.<br />

Sodowsky, G.R., Taffe, R.C., Gutkin, T.B. & Wise, S.L. (1994). Development of the multicultural counseling<br />

inventory: A self-report measure of multicultural competencies. Journal of Consulting Psychology, 41<br />

(2), 137–148.<br />

Stone, G. L. (1997). Multiculturalism as a context for supervision: Perspectives, limitations, and implications.<br />

In D.B. Pope-Davis & H.L.K. Coleman (Eds.), Multicultural Counseling Competencies: Assessment,<br />

Education and Training, and <strong>Supervision</strong> (pp. 263–289). Thousand Oaks, CA: Sage.<br />

Strong, J., Kavanagh, D., Wilson, J., Spence, S.H., Worrall, L. & Crow, N. (2003). <strong>Supervision</strong> practice<br />

for allied health professionals within a large mental health service: Exploring the phenomenon. The<br />

<strong>Clinical</strong> Supervisor, 22 (1), 191–210.<br />

Sue, D.W., Arredondo, P. & McDavis, R.J. (1992). Multicultural counseling competencies and standards:<br />

A call to the profession. Journal of Multicultural Counseling and Development, 20, 64–88.<br />

Sussman, T., Bogo, M. & Globerman, J. (in press). Field instructor competence in small group supervision:<br />

Establishing trust through managing group dynamics. The <strong>Clinical</strong> Supervisor.<br />

Teasdale, K., Brocklehurst, N. & Thom, N. (2001). <strong>Clinical</strong> supervision and support for nurses: An<br />

evaluation study. Journal of Advanced Nursing, 33 (2), 216–224.<br />

Tight, M. (1996). Key Concepts in Adult Education and Training. London, UK: Routledge.<br />

Tripp-Reimer, T., Choi, E., Kelley, K. & Enslein, J. (2001). Cultural barriers to care: Inverting the problem.<br />

Diabetes Spectrum, 14 (1), 13–22.<br />

Tsui, M.S. (2005). Social Work <strong>Supervision</strong>: Contexts and Concepts. Chicago, IL: Sage.<br />

Tummala-Narra, P. (2004). Dynamics of Race and Culture in the Supervisory Encounter. Psychoanalytic<br />

Psychology, 21 (2), 300–311.<br />

White, E., Butterworth, T., Bishop, V., Carson, J., Jeacock, J. & Clements, A. (1998). <strong>Clinical</strong> supervision:<br />

Insider reports of a private world. Journal of Advanced Nursing, 28 (1), 185–192.<br />

White, J.H.D. & Rudolph, B.A. (2000). A pilot investigation of the reliability and validity of the Group<br />

Supervisory Behavior Scale (GSBS). The <strong>Clinical</strong> Supervisor, 19 (2), 161–171.<br />

Winstanley, J. (2000). Manchester <strong>Clinical</strong> <strong>Supervision</strong> Scale. Nursing Standard, 14 (19), 31–32.<br />

Winstanley, J. & White, E. (2003). <strong>Clinical</strong> supervision: Models, measures and best practice. Nurse<br />

Researcher, 10 (4), 7–38.<br />


References<br />

Zwarenstein, M. & Reeves, S. (2006). <strong>Knowledge</strong> translation and interprofessional collaboration: Where<br />

the rubber of evidence-based care hits the road of teamwork. The Journal of Continuing Education in<br />

the Health Professions, 26, 46–54.<br />

Fact Sheet produced by: Liz Lambert, Research Assistant, University of Toronto, which was a summary of<br />

the above articles. Available: www.socialwork.utoronto.ca/competency.<br />


APPENDIX 1<br />

Conceptualization of <strong>Clinical</strong><br />

<strong>Supervision</strong>: A Review of the Literature<br />


<strong>Supervision</strong> in social work is essentially conceived of as a method to ensure the<br />

organization’s mandate is achieved by enhancing the supervisee’s* ability to provide<br />

effective service. The supervisor is accountable for the job performance of agency<br />

workers (Kadushin, 1976; Kadushin & Harkness, 2002) with administrative, educational<br />

and supportive activities being used to achieve this goal. <strong>Supervision</strong> scholars in<br />

social work agree on the importance of a positive relationship between supervisor<br />

and supervisee as the context for learning and performance (Barretta-Herman,<br />

1993; Kadushin & Harkness, 2002; Munson, 2002; Shulman, 1993, 2005) while<br />

emphasizing the parallel process in the working relationship between client-worker<br />

and worker-supervisor.<br />

Three interrelated functions of supervision were proposed by Kadushin (1976)<br />

—administrative, educational and supportive—a conceptualization that has continued<br />

to receive support (Bruce & Austin, 2000; Munson, 2002; Shulman, 1993).<br />

Administrative supervision encompasses selecting and orienting workers/clinicians;<br />

assigning cases; and monitoring, reviewing and evaluating work. It serves as a<br />

socializing agent, advocating, and buffering within the organization. Agencies grant<br />

supervisors authority to direct others’ work and they use both formal power such<br />

as rewards, coercion, position in the organization, and informal power derived from<br />

their expert knowledge and relationships with their supervisees.<br />

*The term supervisee is used in this section to maintain consistnecy with the literature.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Educational supervision encompasses activities that develop the professional capacity<br />

of supervisees, including teaching knowledge and skills, and developing self-awareness<br />

(Barker, 1995; Munson, 2002) through, for example, teaching, case consultation,<br />

facilitating learning and growth. Kadushin and Harkness (2002) note that in the<br />

general social work supervision literature, the term clinical supervision frequently<br />

refers to a focus on the professional practice of the supervisee. Others associate clinical<br />

supervision with an analytic focus on the dynamics of the client situation and the<br />

worker’s interventions and interactions with clients (Gibelman & Schervish, 1997).<br />

We prefer the definition of clinical supervision in professional psychology, which<br />

includes both enhancing the professional performance of the junior member of the<br />

profession while monitoring the quality of services offered to the client (Bernard<br />

& Goodyear, 2004). Supportive supervision encompasses helping workers handle<br />

job-related stress by providing appropriate praise and encouragement, normalizing<br />

work-related reactions, affirming strengths and sharing responsibility for difficult<br />

decisions (Kadushin & Harkness, 2002). Stress is related to the emotional demands<br />

on social workers faced with traumatic and acute social problems that may be<br />

challenging to articulate within the supervision setting (Barretta-Herman, 1993).<br />

Supportive comments are meaningful when given within the context of a relationship<br />

with a respected and valued supervisor (Kaiser & Barretta-Herman, 1999).<br />

In an analysis of themes in the supervision literature, Bruce and Austin (2000) predict<br />

that supervisors in the future would need to incorporate the following: change<br />

management skills including understanding the multiple governmental, community<br />

and organizational contexts of practice; practice in racially and culturally diverse<br />

organizations and communities; use of client outcomes to monitor service delivery;<br />

and processes that promote effective inter-professional work.<br />

In summary, this review of the literature found a view of supervision for social work<br />

that includes the interrelated elements of administration, education and support.<br />

Each of these factors influences all of the others and, when operating in concert,<br />

produce more effective services for clients. Separating educational or clinical elements<br />

from this holistic definition distorts the fundamental essence of social work supervision.<br />

Similar to principles of effective practice, supervision is an interpersonal and interactional<br />

process between worker and supervisor. The importance of offering and<br />

modelling positive elements in a supportive, performance and outcomes-oriented<br />

relationship is reinforced in the literature.<br />


Conceptualization of <strong>Clinical</strong> <strong>Supervision</strong>: A Review of the Literature<br />

Toward an evidence-base for clinical social work supervision<br />

Does the research on social work supervision provide evidence to support this<br />

conceptual model and related principles and practices? Two recent reviews of the<br />

empirical research on social work supervision, one spanning 1970–1995 (Tsui, 1997)<br />

and one spanning 1994–2004 (Bogo & McKnight, 2005) uncovered a dearth of studies<br />

in this regard. The existing studies used small sample sizes, used exploratory, survey<br />

and cross-sectional designs; and contributed modestly to theory-building or providing<br />

evidence for best practices. The studies reviewed, however, did offer some support<br />

for some elements identified in the conceptual literature. For example, Erera and<br />

Lazar (1994) found supervision consisted of the three major functions: administrative,<br />

educational and supportive. A number of studies investigated the organizational<br />

context of supervision and found that the agency’s mandate and focus shape the nature<br />

of supervision provided (Berger & Mizrahi, 2001; Gibelman & Schervish, 1995,<br />

1997; Gleeson & Philbin, 1996). Organizational climate affects supervisors’ and staff<br />

performance and is positively associated with an environment that emphasizes task<br />

orientation, staff involvement, autonomy and clarity of rules (Eisikovits et al., 1985).<br />

Organizational climate also affects satisfaction with greater levels of trust among<br />

colleagues associated with higher satisfaction in child welfare (Silver et al., 1997).<br />

The influential nature of the supervisory relationship was supported (Hensley, 2002).<br />

Administrative, educational and supportive aspects were valued by supervisees and<br />

seen in behaviours such as availability, delegated responsibility to supervisees who<br />

can undertake a task (Granvold, 1978; York, 1996), are knowledgeable about tasks<br />

and skills (Drake & Washeck, 1998; Himle, et al., 1989), are able to relate techniques<br />

to theory (Drake & Washeck, 1998), provide instrumental support (Himle et al., 1989)<br />

and serve as a role model (Drake & Washeck, 1998; Hensley, 2002). General support<br />

was associated with higher worker satisfaction (Newsome & Pillari, 1991; Rauktis &<br />

Koeske, 1994). Workers were more satisfied when they perceived supervisors’ use of<br />

authority as based on their knowledge and skill rather than their middle manager<br />

role (Munson, 1993) and when supervisors communicated in a mutual style (Bowers,<br />

et al., 1999; York & Denton, 1990).<br />


References<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Barker, R.L. (1995). Social work supervision. In Social Work Dictionary. Washington, DC: NASW Press.<br />

Barretta-Herman, A. (1993). On the development of a model of supervision for licensed social work<br />

practitioners. The <strong>Clinical</strong> Supervisor, 11 (2), 55–64.<br />

Berger, C. & Mizrahi, T. (2001). An evolving paradigm of supervision within the changing health care<br />

environment. Social Work in Health Care, 32 (4), 1–18.<br />

Bernard, J.M. & Goodyear, R.K. (2004). Fundamentals of clinical supervision (3rd ed.). Boston, MA:<br />

Pearson.<br />

Bogo, M. & McKnight, K. (2005). <strong>Clinical</strong> supervision in social work: A review of the research literature.<br />

The <strong>Clinical</strong> Supervisor, 24 (1/2), 49–67.<br />

Bowers, B., Esmond, S. & Canales, M. (1999). Approaches to case management supervision.<br />

Administration in Social Work, 23 (1), 29–49.<br />

Bruce, E.J. & Austin, M.J. (2000). Social work supervision: Assessing the past and mapping the future.<br />

The <strong>Clinical</strong> Supervisor, 19 (2), 85–107.<br />

Drake, B. & Washeck, J. (1998). A competency-based method for providing worker feedback to CPS<br />

supervisors. Administration in Social Work, 22 (3), 55-74.<br />

Eisikovits, Z., Meier, R., Guttman, E., Shurka, E. & Levinstein, A. (1985). <strong>Supervision</strong> in ecological context:<br />

The relationship between the quality of supervision and the work and treatment environment. Journal<br />

of Social Service Research, 8 (4), 37–58.<br />

Erera, I.P. & Lazar, A. (1994). The administrative and educational functions in supervision: Indications of<br />

incompatibility. The <strong>Clinical</strong> Supervisor, 12 (2), 39–56.<br />

Gibelman, M. & Schervish, P. H. (1995). Pay equity in social work: Not! Social Work, 40 (5), 622–629.<br />

Gibelman, M. & Schervish, P.H. (1997). <strong>Supervision</strong> in social work: Characteristics and trends in a changing<br />

environment. The <strong>Clinical</strong> Supervisor, 16 (2), 1–15.<br />

Gleeson, J.P. & Philbin, C.M. (1996). Preparing caseworkers for practice in kinship foster care:<br />

The supervisor’s dilemma. The <strong>Clinical</strong> Supervisor, 14 (1), 19–34.<br />

Granvold, D.K. (1978). Training social work supervisors to meet organizational and worker objectives.<br />

Journal of Education for Social Work, 14, 38–45.<br />

Hensley, P.H. (2002). The value of supervision. The <strong>Clinical</strong> Supervisor, 21 (1), 97–110.<br />

Himle, D.P., Jayaratne, S. & Thyness, P.A. (1989). The buffering effects of four types of supervisory<br />

support on work stress. Administration in Social Work, 13 (1), 19–34.<br />

Kadushin, A. (1976). <strong>Supervision</strong> in Social Work. New York, NY: Columbia University Press.<br />

Kadushin, A. & Harkness, D. (2002). <strong>Supervision</strong> in Social Work (4th ed.). New York, NY: Columbia<br />

University Press.<br />

Kaiser, T.L. & Barretta-Herman, A. (1999). The <strong>Supervision</strong> Institute: A model for supervisory training.<br />

The <strong>Clinical</strong> Supervisor, 18 (1), 33–46.<br />

Munson, C.E. (1993). <strong>Clinical</strong> Social Work <strong>Supervision</strong> (2nd ed.). Binghamton, NY: Haworth Press.<br />

Munson, C.E. (2002). <strong>Handbook</strong> of <strong>Clinical</strong> Social Work <strong>Supervision</strong> (3rd ed.). Binghamton, NY: Haworth<br />

Press.<br />


Conceptualization of <strong>Clinical</strong> <strong>Supervision</strong>: A Review of the Literature<br />

Newsome, M. & Pillari, V. (1991). Job satisfaction and the worker/supervisor relationship. The <strong>Clinical</strong><br />

Supervisor, 9 (2), 119–129.<br />

Rauktis, M.E. & Koeske, G. F. (1994). Maintaining social worker morale: When supportive supervision is<br />

not enough. Administration in Social Work, 18 (1), 39–60.<br />

Shulman, L. (1993). Interactional <strong>Supervision</strong>. Washington, DC: NASW Press.<br />

Shulman, L. (2005). The clinical supervisor-practitioner working alliance: A parallel process. The <strong>Clinical</strong><br />

Supervisor, 24 (1/2), 23–47.<br />

Silver, P.T., Poulin, J.E. & Manning, R.C. (1997). Surviving the bureaucracy: The predictors of job<br />

satisfaction for the public agency supervisor. The <strong>Clinical</strong> Supervisor, 15 (1), 1–20.<br />

Tsui, M.S. (1997). Empirical research on social work supervision: The state of the art 1970–1995.<br />

Journal of Social Service Research, 23 (2), 39–51.<br />

York, R.O. (1996). Adherence to situational leadership theory among social workers. The <strong>Clinical</strong> Supervisor,<br />

14 (2), 5–24.<br />

York, R.O. & Denton, R.T. (1990). Leadership behavior and supervisory performance: The view from below.<br />

The <strong>Clinical</strong> Supervisor, 8 (1), 93–108.<br />


Scholars in nursing practice have noted that the multiple definitions, models and<br />

organizational structures create more confusion than clarity in understanding clinical<br />

supervision (Clearly & Freeman, 2005; Cutcliffe & Lowe, 2005; Jones, 2003; Kelly et al.,<br />

2001; Yegdich, 1999).<br />

Definitions<br />

<strong>Clinical</strong> supervision in nursing means different things to various organizations and<br />

the people they employ (Rizzo, 2003) and it becomes difficult to find one definition<br />

that captures all the key elements (Cutcliffe & Lowe, 2005). Butterworth and Faugier<br />

(1992) define clinical supervision as “an exchange between practicing professionals<br />

to assist the development of professional skills” (p. 12). <strong>Clinical</strong> supervision is also<br />

defined as “a practice-focused professional relationship involving a practitioner<br />

reflecting on practice, guided by a skilled supervisor” (UKCC 1996, p. 4).<br />

Jones (2005) reviewed research literature on clinical supervision and credits Winstanley<br />

and White (2003) with the most comprehensive definition: “focusing upon the<br />

provision of empathetic support to improve therapeutic skills, the transmission of<br />

knowledge and the facilitation of reflective practice. The participants have an opportunity<br />

to evaluate, reflect, and develop their own clinical practice and provide a<br />


support system to one another” (p. 8). She further identifies the following aspects of<br />

supervision that have achieved agreement by nurse educators:<br />

• It is a formal growth-focused relationship.<br />

• It provides an opportunity for the supervisor to review the professional<br />

development of a new practitioner.<br />

• It provides a forum for discussing the practice of care.<br />

• It allows colleagues to learn from and encourage each other.<br />

• It reduces professional isolation, emotional strain and stress.<br />

• It may lead to the development of practice theory. (Jones, 2005)<br />

She adds that clinical supervision in the United States is also known in clinical<br />

settings as “the relationship between the nursing staff and an administrative clinical<br />

staff member. This relationship is primarily supportive and evaluative in function<br />

and does not meet the criteria for clinical supervision as defined in the UK” (p.149).<br />

In summary, these definitions, though varied, describe a process in which the supervisee<br />

and the supervisor discuss issues related to the supervisee’s practice, development<br />

and, to some extent, performance.<br />

Models<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Sloan (1999) notes that there is no one model of supervision that can deal with the<br />

diversity of clinical needs found in nursing. Differences in definition, models and<br />

the practice of clinical supervision reflect cultural differences between countries,<br />

organizations and nursing specialties. They also reflect differences between North<br />

American and European conceptualizations of clinical supervision.<br />

In North America, clinical supervision refers to relationships between an administrator<br />

or a superior and a more junior supervisee with the supervisor having supervisory<br />

responsibility for the performance of the supervisee (Cutcliffe & Lowe, 2005).<br />

In Europe, clinical supervision emphasizes professional development and support<br />

for the practitioner (Gilmore, 2001). It also focuses on supervisee-led issues that<br />

range from patient care to interpersonal issues with peers (Cutcliffe & Lowe, 2005).<br />

Similarly Jones (2005) refers to the U.K. model as a mandatory reflective practice<br />

between the supervisee and the supervisor, while in the United States, the model<br />

refers more to a relationship between an expert supervisor and a novice or new<br />


Conceptualization of <strong>Clinical</strong> <strong>Supervision</strong>: A Review of the Literature<br />

nurse supervisee.<br />

Additionally Jones (2005) identifies the three models of clinical supervision found in<br />

the nursing literature:<br />

• the growth model and support model (Faugier, 1992)<br />

• the integrative approach (Hawkins & Shohet, 1989)<br />

• the three function-interactive model (Proctor, 1986).<br />

Growth model<br />

In the growth model, the supervisor facilitates growth both educationally and personally,<br />

assisting in developing clinical autonomy in the supervisee. The focus is on the<br />

relationship aspect of clinical supervision and includes mentorship (Faugier, 1992).<br />

Integrative model<br />

The integrative model divides supervision into four components: supervisor, supervisee,<br />

client and work context. The supervisor and supervisee develop a contract with<br />

negotiated shared tasks and goals (Hawkins & Shohet, 1989).<br />

Three-function interactive model<br />

Proctor’s (1986) three-function interactive model is based on a normative or managerial<br />

function, which promotes and complies with organizational policies. Educational<br />

supervision encompasses activities that develop the professional capacity of supervisees,<br />

including teaching knowledge and skills, and developing self-awareness (Barker, 1995;<br />

Munson, 2002) through, for example, teaching, case consultation, facilitating learning<br />

and growth. This educational component and the restorative or pastoral support<br />

function help the nursing practitioner to understand and manage the emotional<br />

stress of nursing practice.<br />

In the ideal working environment, these models of clinical supervision present benefits<br />

for nursing practice. For instance, several studies have shown that nursing staff<br />

who access clinical supervision acquire a greater readiness to act as well as a greater<br />

openness to change attitudes and outlooks when it comes to:<br />

• solving problems that arise in care relations (Begat et al., 1997; Magnusson et al.,<br />

2002)<br />

• co-ordinating their responses with others (Jones, 2003)<br />

• experiencing greater job satisfaction (Arvidsson et al., 2001; Hyrkäs, 2006)<br />

• improving creativity and organizational climate (Berg & Hallberg, 1999).<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Toward an evidence-base for clinical supervision in nursing<br />

Does the research on clinical supervision in nursing provide evidence to support the<br />

diverse conceptualizations? Two reviews of the empirical research on clinical supervision<br />

in nursing, one spanning 1990–1999 (Williamson & Dodds, 1999), and the other<br />

spanning 1996–2004 (Jones, 2005) found that different aspects of clinical supervision<br />

are widely studied and described in the nursing literature. This growing interest in<br />

clinical supervision, however, derives mainly from Europe (U.K. and the Scandinavian<br />

countries) and from Australia and New Zealand. There is a paucity of research from<br />

North America (Cutcliffe, 2005; Jones, 2005). The studies reviewed employ surveys<br />

and exploratory interviews with descriptive and systematic qualitative designs and<br />

have begun to contribute to an empirical base. However, investigators note that these<br />

studies address the concept of clinical supervision in nursing while lacking a consensus<br />

about the definition of the term or its components (Yegdich, 1999).<br />

The existing studies contribute to the formation of a definition and all provide<br />

support for its utility. For example, Kelly and colleagues (2001) found that managers<br />

(87.5 per cent), supervisors (85.2 per cent), and the great majority of clinical<br />

psychiatric nurse respondents supported the view that supervision can lead to<br />

personal development.<br />

Studies examined the process of clinical supervision. In one study, it was found that<br />

a focus on the nurse “doing” (defined as the nurse-patient relationship) and not on<br />

the nurse “being” (defined as the nurse as a person) made it easier for nurses to talk<br />

about their feelings and actions (Berg & Hallberg, 1999). A number of studies found<br />

that clinical supervision helps nurses gain knowledge and competence, a sense of<br />

security in nursing situations, and a feeling of personal development (Arvidsson et al.,<br />

2001; Jones, 2003; Magnusson et al., 2002). Additionally, Arvidsson and colleagues<br />

(2001) found that supervision gave nurses a sense of feeling independent, increased<br />

energy, fellowship with others and greater job satisfaction.<br />

Format of clinical supervision<br />

The format of clinical supervision has been investigated by a number of researchers.<br />

In a study of nurses in an acute inpatient mental health setting, Cleary and Freeman<br />

(2005) found nurses preferred ad hoc coping methods such as informal sharing and<br />

support of trusted colleagues rather than a more formal approach. These nurses felt<br />

that one-on-one clinical supervision was impossible due to unit constraints. <strong>Clinical</strong><br />

supervision in open groups was difficult to arrange due to staff leaves, rotations and<br />


Conceptualization of <strong>Clinical</strong> <strong>Supervision</strong>: A Review of the Literature<br />

skill mix. In contrast, Kelly et al., (2001) found that one-on-one clinical supervision<br />

was the commonly adopted approach by three-quarters of their sample of nurses<br />

in Northern Ireland. Group supervision was offered to only seven per cent of nurses<br />

surveyed.<br />

Factors contributing to quality of supervision<br />

In investigating the factors that contribute to the quality of supervision, Berg and<br />

Hallberg (1999) found that quality depended on the supervisor’s ability to encourage<br />

and create a permissive atmosphere while Kelly and McKenna (2001) identified the<br />

importance of training. They found that 100 per cent of managers and more than<br />

90 per cent of supervisors and clinical psychiatric nurses strongly supported the<br />

need for supervisor training. They also found an overwhelming majority of all<br />

participants agreed that managers are not the best supervisors.<br />

Rafferty, and colleagues (2003) used a modified Delphi method with expert clinical<br />

supervisors to elicit their perceptions about the multi-dimensional aspects of clinical<br />

supervision and to achieve some consensus about crucial components. They found<br />

three main factors that contribute to effective supervision:<br />

• professional support<br />

• learning<br />

• accountability.<br />

Professional support refers to use of time, supervisory environment and mutuality in<br />

the relationship. Supervisors demonstrated the value of supervision by maintaining<br />

appointment times and defining supervision as part of the work. A positive supervisory<br />

environment was defined as offering consistency, comfort, privacy and the absence<br />

of inappropriate distractions. Relationships were built on mutual respect, choice and<br />

negotiation of ground rules.<br />

The second factor is learning, which refers to focus, knowledge and interventions.<br />

Supervisors assist supervisees to articulate, reflect and make meaning of their activities,<br />

which promotes safety and effective nursing care. <strong>Knowledge</strong> is enhanced when<br />

supervisors elicit explanations and identify supervisees’ abilities and needs for professional<br />

development, when they affirm appropriate practice, support professional<br />

esteem, and encourage the continual need for achievable challenges.<br />

The third factor is accountability, which refers to organizational support, recording,<br />

and competency. The organization must provide the commitment and resources<br />

to enable supervisees and supervisors to receive or offer appropriate supervision.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

A competent supervisor is conscientious about recording processes that specify<br />

content, about knowing who has a right to access information, and recognizing what<br />

constitutes good practice. The maintenance of personal reflective diaries enabled<br />

supervisors to define their own needs for supervision, clarify expectations, and<br />

further develop their skill in supervision.<br />

In summary, clinical supervision researchers in nursing conclude that clinical supervision<br />

is necessary for safe and effective nursing practice and can lead to personal<br />

and professional development (Arvidsson, et al., 2001; Berg & Hallberg, 1999; Kelly<br />

& McKenna, 2001; Rafferty et al., 2003). Nurses, managers and supervisors agree<br />

that the process and format vary depending on the organizational context in which<br />

clinical supervision takes place (Arvidsson, et al., 2001; Berg & Hallberg, 1999;<br />

Jones, 2003; Kelly & McKenna, 2001). Commonly identified elements are:<br />

• positive interpersonal relationships<br />

• affirmation of appropriate practice<br />

• deliberate scheduling of time and space<br />

• reflection and provision of specific applied knowledge<br />

• organizational support<br />

• staff accountability.<br />


A comparison of the social work and nursing literature on clinical supervision reveal<br />

common elements in the approaches offered by Kadushin’s model of three interrelated<br />

functions of social work supervision and Proctor’s three-function interactive model<br />

of nursing supervision. Both models of supervision include an administrative,<br />

supportive and educational component that can lead to increased accountability<br />

and feelings of personal support.<br />

A significant difference between social work and nursing supervision is the lack of<br />

consensus about the definition of clinical supervision in nursing. What is more,<br />

the logistical realities of nursing, including time away from clients, rotating shifts,<br />

24-hour care and stringent time-oriented duties make it challenging to implement<br />

clinical supervision within a nursing environment. By comparison, in many social<br />

work agencies, the daily activities of social work are exempt from many of these<br />

constraints and offer an environment more conducive to regularly scheduled clinical<br />


Conceptualization of <strong>Clinical</strong> <strong>Supervision</strong>: A Review of the Literature<br />

supervision sessions. Finally, social work has a long history of valuing clinical supervision<br />

as the crucial vehicle for professional development of the social worker. By<br />

contrast, in nursing, it appears from the literature that clinical supervision is more<br />

frequently viewed as an authoritarian and hierarchical activity that arises in response<br />

to an error or indiscretion.<br />

References<br />

Arvidsson, B., Löfgren, H. & Fridlund, B. (2001). Psychiatric nurses’ conceptions of how group<br />

supervision programme in nursing care influences their professional competence: A 4-year follow-up<br />

study. Journal of Nursing Management, 9, 161–171.<br />

Begat, I.B.E., Severinsson, E.I. & Bergen, I.A. (1997). Implementation of clinical supervision in a medical<br />

department: Nurses’ views of the effects. Journal of <strong>Clinical</strong> Nursing, 6, 389–394.<br />

Berg A. & Hallberg I.R. (1999). The meaning and significance of clinical group supervision and supervised<br />

individually planned nursing care as narrated by nurses on a general team psychiatric ward. Journal of<br />

Psychiatric and Mental Health Nursing, 6, 371–381.<br />

Butterworth, T, Faugier, J. (1992). <strong>Clinical</strong> <strong>Supervision</strong> and Mentorship in Nursing. London: Chapman<br />

and Hall.<br />

Cleary, M. & Freeman, A. (2005). The cultural realities of clinical supervision in an acute inpatient<br />

mental health setting. Issues in Mental Health Nursing, 26, 489–505.<br />

Cutcliffe, J.R. (2005). From the guest editor—<strong>Clinical</strong> supervision: A search for homogeneity or<br />

heterogeneity? Issues in Mental Health Nursing, 26, 471–473<br />

Cutcliffe, J.R., & Lowe, L. (2005). A comparison of North American and European conceptualizations of<br />

clinical supervision. Issues in Mental Health Nursing, 26, 475–488.<br />

Faugier, J. (1992). The supervisor relationship. In T. Butterworth & J. Faugier (Eds.), <strong>Clinical</strong> <strong>Supervision</strong><br />

and Mentorship in Nursing. London, UK: Chapman and Hall<br />

Gilmore, A. (2001). <strong>Clinical</strong> supervision in nursing and health visiting: A review of the UK literature.<br />

In J.R. Cutcliffe, T. Butterworth & B. Proctor (Eds.), Fundamental Themes in <strong>Clinical</strong> <strong>Supervision</strong><br />

(pp. 125–140). London, UK: Routledge.<br />

Hawkins, P. & Shohet, R. (1989). <strong>Supervision</strong> in the Helping Professions. Milton Keynes: University Press<br />

Hyrkäs, K. (2006). Editorial. <strong>Clinical</strong> supervision: How do we utilize and cultivate the knowledge that we<br />

have gained so far? What do we want to pursue in the future? Journal of Nursing Management, 14, 573–576<br />

Jones, A. (1999). <strong>Clinical</strong> supervision for professional practice. Nursing Standard, 14 (10), 42–44.<br />

Jones, A. (2003). Some benefits experienced by hospice nurses from group clinical supervision. European<br />

Journal of Cancer Care, 12, 224–232.<br />

Jones, J. (2005). <strong>Clinical</strong> supervision in nursing: What’s it all about? The <strong>Clinical</strong> Supervisor, 24 (1/2),<br />

149–162.<br />

Kelly, B., Long, A. & McKenna, H. (2001). A survey of community mental health nurses’ perceptions of<br />

clinical supervision in Northern Ireland. Journal of Psychiatric and Mental Health Nursing, 8, 33–44.<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Magnusson, A., Lützén, K. & Severinsson, E. (2002). Journal of Nursing Management, 10, 37–45.<br />

Proctor, B. (1986). <strong>Supervision</strong>: A co-operative exercise in accountability. In M. Marken & Payne (Eds.),<br />

Enabling and Ensuring. Leicester: National Youth Bureau and Council for Education and Training in<br />

Youth and Community Work.<br />

Rafferty, M. & Coleman, M. (2001). Educating nurses to undertake clinical supervision in practice.<br />

Nursing Standard, 10 (45), 38–41.<br />

Rafferty, M., Jenkins, E. & Parke S. (2003). Developing a provisional standard for clinical supervision in<br />

nursing and health visiting: The methodological trail. Qualitative Health Research, 13 (10), 1432–1452.<br />

Rizzo, M.D. (2003). <strong>Clinical</strong> supervision: A working model for substance abuse acute care settings. Health<br />

Care Manager, 22 (2), 136–143.<br />

Sloan, G. (1999). Understanding clinical supervision from a nursing perspective. British Journal of<br />

Nursing, 8 (8), 524–529.<br />

United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1996). Position statement<br />

on clinical supervision for Nursing, Midwifery and Health Visiting. London: Author.<br />

Williamson, G.R. & Dodds, S. (1999). The effectiveness of a group approach to clinical supervision in<br />

reducing stress: A review of the literature. Journal of <strong>Clinical</strong> Nursing, 8, 338–344.<br />

Winstanley, J. & White, E. (2003). <strong>Clinical</strong> supervison: Models, measures and best practice. Nurse Researcher,<br />

10(4), 7–38.<br />

Yegdich, T. (1999). <strong>Clinical</strong> supervision and managerial supervision: Some historical considerations.<br />

Journal of Advanced Nursing, 30 (5), 1195–1204.<br />


APPENDIX 2<br />

Evaluation For a<br />

<strong>Clinical</strong> <strong>Supervision</strong> Group<br />

PART A<br />

YES NO<br />

Are you currently in supervision elsewhere? ■ ■<br />

If yes, how long have you been in supervision elsewhere? ■ ■<br />

How many times have you attended the clinical supervision group? ■ ■<br />

PART B<br />

YES YES NO<br />


1. The clinical supervision group has helped ■ ■ ■<br />

improve my clinical practice.<br />

If yes, please elaborate on how the clinical supervision group has helped your clinical<br />

practice…<br />

YES YES NO<br />


2. The clinical supervision group makes me<br />

feel more supported in my practice.<br />

■ ■ ■<br />

3. Through the clinical supervision group,<br />

I have learned new ways to approach practice.<br />

■ ■ ■<br />

4. The clinical supervision group has increased<br />

my self-awareness.<br />

■ ■ ■<br />

5. The clinical supervision group has helped me cope<br />

with difficult situations.<br />

■ ■ ■<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

YES YES NO<br />


6. The clinical supervision group has helped<br />

me look more objectively at my work.<br />

■ ■ ■<br />

7. Through attending the clinical supervision group,<br />

I have developed skills in providing peer supervision.<br />

■ ■ ■<br />

8. I feel safe participating in the clinical<br />

supervision group.<br />

■ ■ ■<br />

** If you said somewhat or no to the above question, can you suggest some ways that<br />

would improve safety?<br />

Please comment on the following:<br />

9. What do you feel is missing from the clinical supervision group?<br />

10. What advice do you have for the facilitators?<br />

Developed by Kathy Ryan (2005) in consultation with Ruth Gallop<br />


APPENDIX 3<br />


DATE: _______________________________<br />

As clinician and clinical supervisor, we agree to the following:<br />

• to work together to facilitate in-depth reflection on issues affecting<br />

practice, so developing both personally and professionally to develop<br />

a high level of clinical expertise.<br />

• to meet on average once per week as a group for one hour.<br />

• to protect the time and space for clinical supervision, by keeping to<br />

agreed appointments and time boundaries. Privacy will be respected<br />

and interruptions avoided.<br />

• to provide a record for our employer, showing the times and the dates<br />

of the clinical supervision sessions.<br />

• We will work to the clinician’s agenda, within the framework and focus<br />

negotiated at the beginning of each session. However, the clinical<br />

supervisor reserves the right to highlight items apparently neglected<br />

or unnoticed by the clinician.<br />

• We will work respectfully, both of us being open to feedback about<br />

how we handle the clinical supervision sessions.<br />

We both agree to challenge aspects of this agreement that may be<br />

in dispute.<br />

As a clinician I agree to:<br />

• prepare for the sessions, for example, by having an agenda or<br />

preparing notes, videos, observation opportunities, audiotapes.<br />

• take responsibility for making effective use of the time (including<br />

punctuality), the outcomes and any actions I may take as a result<br />

of clinical supervision.<br />

• Be willing to learn, to develop my clinical skills and be open to<br />

receiving support and challenge.<br />

117<br />

continue next page...

As a clinical supervisor I agree to<br />

• Keep all information you reveal in the clinical supervision sessions<br />

confidential, except for these exceptions:<br />

– You describe any unsafe, unethical, or illegal practice that you are<br />

unwilling to go through the appropriate procedures to address.<br />

– You repeatedly fail to attend sessions.<br />

• In the event of an exception arising, I will attempt to persuade and<br />

support you to deal appropriately with the issue directly yourself.<br />

If I remain concerned, I will reveal the information only after informing<br />

you that I am going to do so.<br />

• At all times work to protect your confidentiality.<br />

• Not allow procedural issues of the work to monopolize the clinical<br />

supervision session.<br />

• Offer you advice, support, and supportive challenge to enable you<br />

to reflect in depth on issues affecting your practice.<br />

• Be committed to continually developing myself as a practicing<br />

professional.<br />

• Keep a record of our clinical supervision sessions.<br />

• Ask for feedback for the purpose of evaluating the clinical supervision<br />

process.<br />

• Use my own clinical supervision to support and develop my own<br />

abilities as a clinical supervisor and clinician, without breaking<br />

confidentiality.<br />

Anything else?<br />

Frequency of Meetings<br />

Venue<br />

Duration of <strong>Clinical</strong> <strong>Supervision</strong> Relationship<br />

Next Review Date<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Signed Signed<br />

(Clinician) (<strong>Clinical</strong> Supervisor)<br />

Thank you for completing this questionnaire!<br />

Adapted from Bolton Primary Care Trust (2003). <strong>Clinical</strong> <strong>Supervision</strong> Guidance Document. Available at<br />

www.bolton.nhs.uk/foi_pubscheme/policy_store. Accessed January 15, 2008<br />


APPENDIX 4<br />

Core <strong>Clinical</strong> Practice Competencies<br />

This document has been developed to articulate the practice competencies required<br />

by camh clinicians of all professional disciplines. Each discipline has unique<br />

domains and standards of practice determined by a regulatory body and/or professional<br />

association. All camh clinicians must maintain membership in good standing<br />

in their college or professional association. This document is offered as a guide to<br />

the essential competencies required of all professionals in the organization. Other<br />

documents such as the camh Code of Conduct, camh Leadership Profile and camh<br />

Values and Mission Statement also delineate expectations of camh staff. This document<br />

is specifically intended for use by camh clinicians to improve clinical practice and<br />

client care. It may act as a framework by which camh clinicians develop learning plans,<br />

monitor practice, set career milestones, and create professional development goals. It<br />

may also act as a guideline for reviewing competency at each level of development.<br />

Additionally, it may be used by:<br />

• camh staff involved in orientation of students and new staff<br />

• clients and other people using camh services to better understand the various<br />

levels of practice of camh clinicians<br />

• apn /apc / discipline chiefs and program managers to create a context for guiding<br />

and evaluating the practice of supervisees<br />

• camh administrators to effectively distinguish, maintain and further refine<br />

standards of practice of camh clinicians, and to support them in the hiring and<br />

retention of individuals with the necessary knowledge and skills required to<br />

meet the needs of clients.<br />

This document has been organized along a continuum of practice in order to<br />

acknowledge that clinicians acquire knowledge and skills over time and that practice<br />

matures in recognizable and definable ways. In domains of practice common to all<br />

mental health and addictions professionals—therapeutic relationships, assessment,<br />


intervention, evaluation, professionalism, collaborative practice—these core<br />

competencies provide common language about job and performance expectations.<br />

Ultimately, the development of these competencies across the organization will ensure<br />

that camh clinicians are current in providing clients with evidence-based practices.<br />

Three distinct levels of practice are delineated and each level coincides with the<br />

development of practice as clinicians continue to gain skill, knowledge and professional<br />

wisdom. It is possible that one may practice at a higher or lower level in certain<br />

domains but the level of practice is defined by where one most consistently practices,<br />

keeping all areas in mind. The same levels are for use across disciplines, and each<br />

discipline has its own body of work and expertise, so the skills and behaviours practised<br />

at each level will be different for each discipline. Each level of practice builds upon the<br />

previous one, with increasingly greater competency, proficiency and excellence in the<br />

breadth and depth of practice. It is also written in such a way that each clinical program<br />

can adapt it more specifically to the particular needs of their client population.<br />


The levels of practice identified here are:<br />

• competent practice<br />

• proficient practice<br />

• expert practice.<br />

Competent practice<br />

Competent practice is characterized by entry-level clinical knowledge and skill by<br />

a clinician who has completed an accredited educational program of study. The<br />

competent clinician requires ongoing clinical supervision in order to become<br />

proficient in specific knowledge and skill areas.<br />

Proficient practice<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

Proficient practice is characterized by specialized clinical knowledge and skill whereby<br />

the clinician is practising at an autonomous or intermediate level (typically three<br />

years of experience in a specialized mental health/addiction field). The proficient<br />

clinician is a recognized role model, student preceptor, clinical resource and leader<br />

demonstrating clinical mastery and commitment to achieving program goals while<br />

continuing to seek improvement through clinical supervision or consultation.<br />


Expert practice<br />

Expert practice is characterized by the ability to lead, direct, support and influence<br />

clinical practice within the organization. This clinician possesses intuition and has<br />

developed a specialized knowledge and skill level that is grounded in higher education<br />

and practical experience (typically five or more years). The expert clinician teaches,<br />

supervises and consults with other members of the health care team. He or she takes<br />

on an active part in the achievement of program goals.<br />

NOTE: The term “client” is used to inclusively refer to individuals and their families,<br />

groups or communities serviced by camh clinicians. However, the “client” of the<br />

expert clinician is often clinical staff functioning at competent and/or proficient levels<br />

of practice or the organization itself. “Family” is whoever the client determines his<br />

or her family to be.<br />


The following chart outlines the domains of practice required for clinicians at<br />

camh. The domains are:<br />

• clinician-client relationship<br />

• family and social support<br />

• professional autonomy and accountability<br />

• embracing cultural diversity<br />

• clinical assessment: interviewing, formulation, treatment planning and<br />

documentation<br />

• therapeutic interventions with clients, groups and families: practice,<br />

documentation and case management<br />

• anticipation and responding to rapidly changing situation<br />

• program development, implementation and evaluation of care<br />

• outreach<br />

• teamwork, collaboration and partnerships<br />

• ethical, organizational and legal accountabilities<br />

• professional development and research<br />

• consultation and education<br />

Core <strong>Clinical</strong> Practice Competencies<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />



Proficient Expert<br />

Possesses expert knowledge,<br />

skill and intuition and applies<br />

the competency in the most<br />

complex situations at various<br />

levels within and across the<br />

organization<br />

Possesses specialized, advanced<br />

clinical knowledge and skill and<br />

practices autonomously across<br />

a wide range of increasingly<br />

complex clinical situations<br />

Competent<br />

Possesses entry-level clinical<br />

knowledge and skill and has<br />

knowledge and skill to implement<br />

the competency in routine<br />

practice in a variety of clinical<br />

situations<br />


• Engages in and role-models<br />

excellence in therapeutic<br />

relationships with clients as<br />

well as professional relationships<br />

with supervisees and<br />

other staff<br />

• Demonstrates high level of<br />

self-awareness and able to not<br />

only acknowledge own personal<br />

• Demonstrates mastery in<br />

effectively engaging in, maintaining<br />

and terminating<br />

therapeutic relationships<br />

• Models therapeutic relationships<br />

with clients and demonstrates<br />

the same principles in<br />

relationships with students,<br />

staff and larger systems<br />

• Understands that the therapeutic<br />

relationship between<br />

clinician and client is foundational<br />

to effective mental<br />

health and addiction practice<br />

• Facilitates therapeutic relationships<br />

with clients that:<br />

– focus on trust, respect,<br />

compassion, empathy and<br />

Clinician-Client Relationship<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

values, transference/countertransference<br />

and, parallel<br />

process issues and respond<br />

accordingly but also intuitively<br />

anticipates the same<br />

• Effectively demonstrates<br />

differential use of self in<br />

therapeutic relationships<br />

• Fosters, and consistently<br />

monitors, the environment to<br />

ensure that clients and<br />

clinicians are safe from abuse<br />

• Provides ongoing training and<br />

clinical supervision to assist<br />

and support staff in engaging<br />

in effective therapeutic relationships<br />

following the guidelines,<br />

values and principles<br />

outlined in the camh <strong>Clinical</strong><br />

<strong>Supervision</strong> handbook<br />

• Provides debriefing after<br />

critical incidents involving<br />

clinicians and clients<br />

• Seeks consultation with<br />

colleagues as needed<br />

• Demonstrates high level of<br />

self-awareness and an ability<br />

to respond effectively to<br />

transference and countertransference<br />

issues<br />

• Promptly and effectively<br />

addresses any inequitable or<br />

discriminatory behaviours<br />

toward clients, families and<br />

others at camh<br />

• Advocates on behalf of the<br />

client and champions camh<br />

Bill of Client Rights<br />

• Provides guidance, support,<br />

knowledge and skills to staff<br />

and students in understanding,<br />

creating and maintaining<br />

therapeutic relationships<br />

• Seeks supervision as needed<br />

regarding to clinician-client<br />

relationship issues<br />

client strengths<br />

– promote and provide biopsychosocial-spiritual<br />

and<br />

cultural comfort and<br />

sensitivity to clients<br />

– protect client confidentiality<br />

– respect client autonomy,<br />

dignity, privacy and rights<br />

• Demonstrates self-awareness<br />

of his or her beliefs, values,<br />

social location and culture<br />

and their influence on therapeutic<br />

relationships<br />

• Responds appropriately when<br />

differences arise between self<br />

and clients from diverse<br />

groups<br />

• Ensures that appropriate<br />

boundaries between professional<br />

therapeutic relationships<br />

and non-professional<br />

personal relationships are<br />

maintained<br />

• Recognizes when triggers<br />

Clinician-Client Relationship<br />

continued<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

regarding staff-client issues<br />

that arise with supervisees or<br />

with own clients<br />

occur (e.g., own “buttons”<br />

are pushed) and responds<br />

appropriately seeking supervision<br />

as necessary<br />

• Assumes a wellness and<br />

recovery perspective<br />

• Creates a safe, respectful and<br />

caring environment for clients<br />

• Communicates with respect<br />

• Uses language that is nonstigmatizing.<br />

• Seeks out guidance, support,<br />

knowledge, skills and regular<br />

supervision with respect to<br />

therapeutic relationships and<br />

clinical work<br />

Clinician-Client Relationship<br />

continued<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

Family and Social Support • Understands the impact of • Has a comprehensive knowl- • Recognized as an expert in<br />

family functioning on mental edge of family systems theory, one or more models of family<br />

health/illness/addictions<br />

family process, dynamics and therapy practice<br />

• Values and appropriately<br />

functioning<br />

• Provides family therapy<br />

includes family and social • Understands the impact of training and supervision<br />

support systems in the<br />

illness on family functioning across the Centre and at<br />

assessment, planning and and family functioning on local, provincial and national<br />

treatment of client care<br />

illness<br />

forums<br />

• Is able to assess family needs • Conducts family assessments<br />

and how best to involve them using evidence-based models<br />

in the client’s care<br />

• Purposefully works with client<br />

• Shares knowledge of commu- and family to enhance family<br />

nity supports and resources functioning and cohesion<br />

for families with a member using evidence-based family<br />

experiencing mental health therapy models<br />

and/or addiction problem(s) • Able to provide treatment that<br />

• Seeks out family therapy<br />

emphasizes family as the unit<br />

training and supervision<br />

of care<br />

• Supervises others in family<br />

therapy<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Uses standards of practice,<br />

legislation, ethical and legal<br />

knowledge to clarify scope of<br />

practice for self and others<br />

• Anticipates factors that may<br />

interfere with professional<br />

autonomy of staff situation<br />

(i.e., staffing ratios, low staff<br />

morale) and seeks to remedy<br />

• Shares and models dissemination<br />

of evidence-based<br />

practices to continuously<br />

improve outcomes for clients<br />

and families experiencing<br />

mental health and / or<br />

addiction problems<br />

• Displays strong leadership<br />

skills within the program,<br />

organization and community<br />

to influence the profession,<br />

mental health and addiction<br />

health care, and the provincial<br />

health care system<br />

• Monitors, refines and advances<br />

standards of practice in his or<br />

her profession and program<br />

• Shares knowledge and expertise<br />

with other clinicians and<br />

students to meet client need<br />

• Informs competent staff<br />

and students of resources<br />

available to support their<br />

practice, consolidation and<br />

development<br />

• Displays initiative for new<br />

ideas within the program and<br />

organization<br />

• Works within program,<br />

organization and community<br />

to decrease stigma associated<br />

with mental health and<br />

addiction<br />

• Works autonomously and<br />

makes clinical decisions seeking<br />

supervision appropriately<br />

as needed<br />

• Understands her or his scope<br />

of practice, and seeks timely<br />

assistance from proficient<br />

and expert clinicians<br />

• Recognizes and embraces<br />

the importance and value of<br />

helping relationships<br />

• Demonstrates a commitment<br />

to helping clients and families<br />

achieve their goals<br />

• Practises honesty, dignity,<br />

respect, compassion and<br />

integrity with each individual<br />

and family<br />

• Honours and maintains client<br />

and family confidentiality<br />

• Understands the influence of<br />

stigma on clients and supports<br />

clients and family who feel<br />

stigmatized<br />

• Maintains competency and<br />

refrains from activities<br />

in which he or she is not<br />

competent<br />

Professional Autonomy<br />

and Accountability<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Has comprehensive and<br />

detailed knowledge and skill<br />

in working with diverse populations<br />

and applies to program<br />

planning and evaluation<br />

• Is a recognized expert in<br />

diversity training and provides<br />

consultation to specialized<br />

populations, colleagues and<br />

other health care professionals<br />

who are learning to implement<br />

culturally sensitive care<br />

• Possesses extensive knowledge<br />

of diversity issues and<br />

delivers culturally sensitive<br />

care to individuals, agencies<br />

and communities<br />

• Mentors colleagues in diversity<br />

training<br />

• Helps diverse client populations<br />

to implement programs<br />

in their communities<br />

• Understands, identifies and<br />

responds to issues of diversity<br />

and how they influence client<br />

health and illness<br />

• Incorporates knowledge of<br />

cultural and socio-economic<br />

issues and develops effective<br />

working relationships with<br />

various client populations<br />

within and outside of camh<br />

Embracing Cultural Diversity<br />

• Recognized by others as<br />

expert in assessment<br />

processes<br />

• In own clinical practice and in<br />

supervising others, is able to<br />

take a meta-perspective on<br />

client/family situation and<br />

rapidly synthesize and interpret<br />

multiple levels of data in<br />

complex client and family<br />

assessment situations<br />

• Demonstrates a whole<br />

systems perspective in clinical<br />

interviewing, formulation and<br />

documentation<br />

• Able to independently<br />

conduct family assessments<br />

utilizing a systemic,<br />

strengths-based approach<br />

• Has acquired and applies<br />

substantial knowledge of<br />

clinical assessment process,<br />

• Collaborates with clients and<br />

other members of the health<br />

care team to complete comprehensive<br />

assessments that<br />

consider mental, psychological,<br />

social, spiritual and physical<br />

health<br />

• Demonstrates sensitivity to<br />

client gender and diversity<br />

issues<br />

• Selects, applies and interprets<br />

<strong>Clinical</strong> Assessment:<br />

Interviewing, Formulation,<br />

Treatment Planning and<br />

Documentation<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Applies development research<br />

in evaluating assessment<br />

tools and instruments to<br />

measure clinical outcomes<br />

• Teaches, champions and<br />

advances innovative knowledge<br />

in assessment practices—<br />

interviewing, formulation,<br />

treatment planning and camh<br />

documentation initiatives<br />

(e.g., electronic health record)<br />

• Demonstrates masterful<br />

knowledge, skill and experience<br />

in understanding and enhancing<br />

client motivation<br />

• Demonstrates masterful<br />

knowledge, skill and experience<br />

in developing plans of care in<br />

complex clinical situations<br />

that honour and respect client<br />

goals particularly when goals<br />

of client and family differ<br />

from those of the clinician<br />

• Transfers knowledge and<br />

provides supervision to<br />

measurement tools, and<br />

evidence-based treatments<br />

for clinical population<br />

• Demonstrates advocacy for<br />

clients at a higher organizational<br />

level (e.g., odsp)<br />

• Demonstrates knowledge of<br />

tools for special populations<br />

(e.g., t-ace (screening for<br />

alcohol dependence in<br />

pregnant women)<br />

• Responds to issues of culture<br />

and diversity in a purposeful<br />

manner, building on client<br />

strengths and seeking additional<br />

supports and resources<br />

as needed<br />

• Identifies barriers within the<br />

care delivery process that can<br />

impact on client goals being<br />

achieved<br />

• Designs treatment plans for<br />

complex, sensitive situations<br />

that require substantial<br />

co-ordination between services<br />

evidence-informed screening<br />

and/or assessment tools<br />

• Utilizes cultural assessments<br />

tools<br />

• Understands and utilizes evidence-based<br />

tools appropriate<br />

to the client’s situation (i.e.,<br />

subscribed outcome tools in<br />

treat, mse, dsm iv, ciwa-a<br />

cage and physical examination<br />

including screening for<br />

co-morbidity)<br />

• Understands and takes into<br />

account social determinants<br />

of health (i.e., poverty,<br />

employment, housing, health,<br />

social support, past trauma)<br />

during the assessment<br />

• Understands the influence of<br />

having an addiction on mental<br />

health and of mental health<br />

problems on the development<br />

of an addiction<br />

• Considers concurrent disorders<br />

in assessment:<br />

<strong>Clinical</strong> Assessment:<br />

Interviewing, Formulation,<br />

Treatment Planning and<br />

Documentation continued<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

others, ensuring clinical<br />

integrity in clinical assessment<br />

practices—<br />

interviewing, formulation<br />

and documentation<br />

• Engages with the client and<br />

other resources to adjust the<br />

treatment plan as needed<br />

• Works with staff to help<br />

bridge any gaps between<br />

client goals and clinician<br />

goals for client and develops<br />

strategies to enhance client<br />

motivation<br />

• Coaches and/or mentors<br />

others to ensure clinical<br />

integrity in assessment<br />

processes—interviewing,<br />

formulation, treatment<br />

planning and documentation<br />

• Seeks supervision as needed<br />

with respect to interviewing,<br />

formulation and<br />

documentation<br />

– able to screen for alcohol<br />

and other drug problems,<br />

dependence, symptoms of<br />

withdrawal and intoxication<br />

– able to take a history of<br />

alcohol and drug consumption,<br />

consequences of<br />

alcohol and drug use<br />

(physical and social);<br />

assess sexual practices,<br />

injection drug use, driving<br />

while impaired<br />

• Considers trauma factors<br />

in assessment<br />

• Ensures physical health<br />

issues are included in<br />

assessment<br />

• Assesses clients’ need for<br />

language support<br />

• Formulates an individualized,<br />

comprehensive plan of care<br />

with the client to accurately<br />

respect and reflect the complexity<br />

of client values, preferences,<br />

needs and goals and<br />

<strong>Clinical</strong> Assessment:<br />

Interviewing, Formulation,<br />

Treatment Planning and<br />

Documentation continued<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

that integrates evidencebased<br />

treatment modalities<br />

• Recognizes and respects<br />

clients’ unique differences,<br />

strengths and barriers and<br />

customizes individual plans<br />

of care accordingly<br />

• Determines and shares with<br />

the client the treatment plan,<br />

monitors course of treatment<br />

and assists clients experiencing<br />

setbacks<br />

• Documents client assessments<br />

in a clear, concise and<br />

timely manner on camhapproved<br />

forms (e.g., eIPCC)<br />

and in accordance with camh<br />

documentation policies and<br />

guidelines<br />

• Seeks assistance from experienced<br />

staff in all aspects of<br />

clinical assessment<br />

<strong>Clinical</strong> Assessment:<br />

Interviewing, Formulation,<br />

Treatment Planning and<br />

Documentation continued<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Recognized as an expert in<br />

providing individual, group<br />

and/or family therapy utilizing<br />

most effective evidence-based<br />

approaches in a flexible,<br />

innovative and confident<br />

self-directed approach<br />

• Communicates and models<br />

excellence in client care<br />

• Effectively facilitates group<br />

therapy in which complex<br />

issues arise (e.g., disruptive<br />

behaviours, disengaged members)<br />

and provides others in<br />

the field with group therapy<br />

supervision or published<br />

materials<br />

• Evaluates evidence-based<br />

approaches for mental health<br />

and/or addiction treatment<br />

• Creates a program context<br />

that supports quality practice<br />

• Forms partnerships to facilitate<br />

programs within and<br />

outside of camh<br />

• Has substantial knowledge of<br />

and skills related to client,<br />

group and/or family specific<br />

interventions (e.g.,<br />

Motivational Interviewing,<br />

cbt, dbt, ipt, ccrt, family<br />

therapy)<br />

• Delivers and models above<br />

interventions using a whole<br />

systems perspective<br />

• In group therapy, recognizes<br />

difficult group dynamics and<br />

facilitates discussion to<br />

resolve issues while achieving<br />

group goals<br />

• Demonstrates an ability to<br />

make autonomous clinical<br />

decisions<br />

• Applies a variety of mechanisms<br />

to ensure excellence in<br />

clinical care (e.g., client<br />

satisfaction, accreditation)<br />

• Provides mentorship to staff<br />

with respect to clinical practice,<br />

documentation and case<br />

• Ensures that his or her practice<br />

is grounded in theory and<br />

applies evidence-based practices<br />

to meet specific client<br />

and family mental health<br />

and/or addiction concerns<br />

and needs<br />

• Delivers client-, group- and<br />

family-centred interventions<br />

in a non-judgmental and nondiscriminatory<br />

manner<br />

• Tailors interventions to meet<br />

developmental and cultural<br />

needs of the client and family<br />

• Understands group dynamics<br />

and is able to effectively<br />

facilitate group therapy,<br />

engaging the group while<br />

accommodating needs of<br />

specific individuals<br />

• Understands how to access,<br />

and subsequently provides,<br />

appropriate information and<br />

resources to clients and<br />

families to help them<br />

Therapeutic Interventions with<br />

Clients, Groups and Families:<br />

Practice, Documentation and<br />

Case Management<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Ensures resources are available<br />

across the organization<br />

for staff to provide most<br />

effective treatments for clients<br />

• Develops opportunities for<br />

client education and empowerment<br />

and demonstrates<br />

leadership in the field at local,<br />

and national educational<br />

events and programs<br />

• Develops policies and practices<br />

to meet needs of diverse<br />

populations<br />

• Sets standards of excellence<br />

for client care<br />

• Develops, modifies and<br />

evaluates camh documentation<br />

policies, practices and<br />

forms to continuously<br />

improve client and family care<br />

management issues<br />

• Forms partnerships with<br />

community groups<br />

• Seeks supervision as needed<br />

with respect to clinical practice,<br />

documentation and case<br />

management<br />

participate in and/or make<br />

informed decisions about<br />

their care and treatments<br />

• Advocates on behalf of client;<br />

shares knowledge of advocacy<br />

resources available to clients<br />

and families internally and<br />

externally<br />

• Supports family members<br />

• Seeks supervision or<br />

resources / evidence needed<br />

to inform safe, effective clinical<br />

practice<br />

Therapeutic Interventions with<br />

Clients, Groups and Families:<br />

Practice, Documentation and<br />

Case Management continued<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Takes leadership in developing,<br />

modifying and evaluating<br />

policy and practice guidelines<br />

regarding to emergency codes<br />

• Explicitly identifies, anticipates<br />

and foresees an emergency<br />

code (e.g., client appearing<br />

aggravated and becoming<br />

increasingly defiant) and<br />

prevents it from occurring<br />

with de-escalation strategies<br />

• Provides debriefing and<br />

supervision to staff after critical<br />

incidents (i.e., code white,<br />

code Blue) involving staff<br />

and clients<br />

• Regularly analyses code<br />

functioning with team<br />

• Invites external perspectives<br />

on risk assessment and<br />

mitigating strategies<br />

• Provides leadership, intervention<br />

and support in all camh<br />

emergency codes<br />

• Supports and educates staff<br />

and students according<br />

emergency codes<br />

• Modifies environment to<br />

minimize occurrence of codes<br />

(e.g., triggers to a code white)<br />

• Continuously assesses and<br />

anticipates psychiatric emergencies<br />

(e.g., self harm, harm<br />

to others) within specified<br />

client population using<br />

evidence-based tools<br />

• Recognizes symptoms and<br />

risk of withdrawal from<br />

alcohol and / or drugs and<br />

responds in a timely manner<br />

using evidence-based<br />

protocols<br />

• Analyzes and interprets<br />

unusual client responses and<br />

responds in a timely manner<br />

• Creates and documents<br />

safety plans<br />

• Recognizes role in a code<br />

white and for nursing staff,<br />

or a code blue<br />

• Familiar with policies and procedures<br />

related to emergency<br />

responses (e.g., codes blue,<br />

white, red) and participates in<br />

educational opportunities on<br />

Anticipating and Responding to<br />

Rapidly Changing Situations<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

these codes<br />

• Demonstrates ability to intervene<br />

appropriately with<br />

clients assessed to be at risk<br />

of harm to self or others<br />

• Seeks immediate assistance<br />

in rapidly changing situations<br />

that exceed level of competence<br />

or confidence<br />

Anticipating and Responding to<br />

Rapidly Changing Situations<br />

continued<br />

• Leads team in program development,<br />

implementation and<br />

evaluation across programs,<br />

camh as an organization<br />

and within the community<br />

• Acts as leader for camh in<br />

addressing gaps for specialized<br />

populations at local,<br />

provincial or national level<br />

and incorporates findings<br />

into ongoing program<br />

development<br />

Proficient<br />

• Demonstrates global perspective<br />

on developing, implementing<br />

and evaluating client<br />

care programs<br />

• Leads team and supervises<br />

others in generating ideas for<br />

new programs or modifying<br />

existing ones, and in implementing<br />

and evaluating<br />

programs<br />

• Collaborates effectively with<br />

colleagues involved in the<br />

Competent<br />

• Recognizes, respects and<br />

validates client and family<br />

goals in the development,<br />

implementation and evaluation<br />

of camh approaches<br />

to care<br />

and programs<br />

• Identifies need for refining<br />

current approaches to care<br />

and/or for developing new<br />

approaches or programs<br />

of care<br />

Program Development,<br />

Implementation and Evaluation<br />

of Care<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Is a recognized expert<br />

and leader in program<br />

development, planning<br />

and evaluation<br />

program development and<br />

evaluation<br />

• Applies knowledge of<br />

research methodologies in<br />

analysing data<br />

• Independently writes reports<br />

related to program changes,<br />

development of new programs<br />

and evaluation of programs<br />

• Plans and implements new<br />

programs and utilizes analytical<br />

skills to evaluate them<br />

• Evaluates outcomes of treatment<br />

in light of client and<br />

health care team goals and<br />

modifies plans with client and<br />

team accordingly<br />

• Contributes to reports related<br />

to modifying or designing<br />

new approaches or programs<br />

Program Development,<br />

Implementation and Evaluation<br />

of Care continued<br />

• Is a recognized expert for<br />

designing outreach programs<br />

for specialized populations<br />

• Identifies gaps in outreach<br />

programs and collaborates<br />

with community partners to<br />

improve and modify existing<br />

programs or create new ones<br />

• Provides supervision and<br />

leadership across camh and<br />

supports programs to be<br />

delivered within communities<br />

• Delivers a variety of evidencebased<br />

outreach services in<br />

the community<br />

• Supports and supervises<br />

others to design and deliver<br />

culturally sensitive outreach<br />

services<br />

• Demonstrates good understanding<br />

of outreach needs<br />

in a community within<br />

specialized population<br />

• Participates in program delivery<br />

and evaluation of culturally<br />

sensitive outreach programs<br />

based on evidence-based<br />

practices<br />

• Seeks out necessary supervision<br />

in delivering and<br />

evaluating outreach programs<br />

Outreach<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Creates a team culture that<br />

facilitates collaboration on<br />

multiple dimensions within<br />

multiple systems to improve<br />

client care<br />

• Teaches, coaches and mentors<br />

staff and draws forth their<br />

strengths<br />

• Offers supervision that is consistent<br />

with qualities of a<br />

supervisor-supervisee relationship<br />

as outlined in the camh<br />

<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong><br />

• Creates opportunities to<br />

develop clinicians into leaders<br />

• Possesses community development<br />

skills and pursues<br />

partnerships with other internal<br />

and external providers<br />

• Fosters innovation, creativity<br />

and commitment to organizational<br />

change<br />

• Builds partnerships with<br />

various levels of government<br />

to champion the agenda of<br />

camh<br />

• Possesses excellent understanding<br />

and demonstrates<br />

skill related to effective team<br />

dynamics and functioning<br />

• Successfully assists staff to<br />

manage conflicts that arise<br />

within the team<br />

• Shares information directly<br />

and openly and will engage in<br />

difficult conversations<br />

• Builds teams that work well<br />

together, experience trust,<br />

openness and flexibility<br />

• Creates team context that<br />

effectively addresses conflict<br />

and ambiguity<br />

• Works with team differences<br />

to develop a stronger, more<br />

effective team<br />

• Addresses power dynamics<br />

• Demonstrates knowledge of<br />

the roles of various members<br />

of the team<br />

• Displays initiative, works collaboratively<br />

within the team,<br />

asks questions, exercises<br />

professional judgment and<br />

seeks consultation as needed<br />

• Recognizes potential for conflict<br />

and applies basic conflict<br />

resolution strategies<br />

• Possesses knowledge and<br />

skill in professional communication,<br />

leadership and<br />

negotiation strategies<br />

• Works positively within team<br />

to effectively transform situations<br />

of conflict into healthier<br />

interpersonal interactions<br />

• Demonstrates good understanding<br />

of team and group<br />

dynamics<br />

• Embraces and behaves in<br />

accordance with camh values<br />

and strategic direction<br />

Team Work, Collaboration and<br />

Partnerships<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Recognized as an expert in<br />

ethics in the field of mental<br />

health and addiction<br />

• Collaborates with other health<br />

care professionals to challenge<br />

and co-ordinate institutional<br />

resources to achieve the most<br />

effective outcomes<br />

• Creates environments within<br />

camh and with external partners<br />

that promote safe, ethical,<br />

legal, professional practice<br />

and deals effectively with staff<br />

and/or clients when ethical<br />

issues arise<br />

• Leads accreditation and quality<br />

improvement initiatives at<br />

organizational level and in<br />

collaboration with camh<br />

external partners<br />

• Represents camh externally<br />

(e.g., committees, media,<br />

community development<br />

projects) as a leader in a<br />

• Advocates for the best possible<br />

care for clients, for her or<br />

his profession and for the<br />

health care system<br />

• Engages self and staff in critical<br />

thinking about identifying and<br />

resolving ethical issues,<br />

concerns and dilemmas<br />

• Works with camh partners to<br />

ensure compliance to standards<br />

of professional, ethical<br />

practice<br />

• Creates manageable staff<br />

workload and scheduling for<br />

staff giving them sufficient<br />

time to discuss and plan care<br />

with colleagues<br />

• Leads accreditation and quality<br />

improvement initiatives at<br />

program level<br />

• Represents program and / or<br />

camh in internal / external<br />

committees<br />

• Has a strong working knowledge<br />

of legislation in caring<br />

• Identifies and understands<br />

ethical concerns, issues and<br />

dilemmas as they pertain to<br />

the client-clinician relationship<br />

and to the larger field of<br />

mental health and addictions<br />

• Demonstrates knowledge of<br />

the implications of ethical issues<br />

in interactions with clients<br />

experiencing mental health<br />

and/or addiction problems<br />

• Collects and uses available<br />

resources from various<br />

sources to resolve ethical<br />

issues<br />

• Has a good working knowledge<br />

of ethics and is able to<br />

make ethical decisions<br />

• Is knowledgeable about camh<br />

values, policies, procedures,<br />

program specific initiatives<br />

and strategic directions<br />

• Demonstrates awareness<br />

of relevant legislation that<br />

guides practice<br />

Ethical, Organizational and<br />

Legal Accountabilities<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

specialized field of mental<br />

health and / or addiction<br />

practice and / or research<br />

for clients and families in his<br />

or her specialized mental<br />

health and / or addictions<br />

field<br />

• Ensures client safety and<br />

protects the client from abuse;<br />

reports unsafe practices<br />

• Organizes workload and<br />

develops time management<br />

skills to meet responsibilities<br />

• Integrates quality improvement<br />

initiatives into practice<br />

• Completes all required workload<br />

measurements in a timely,<br />

professional manner<br />

• Completes documentation<br />

in accordance with camh<br />

standards<br />

• Displays commitment to<br />

continuous quality improvement<br />

(i.e., cqi, InfoMed)<br />

• Participates in program and<br />

camh internal/external<br />

committees<br />

Ethical, Organizational and<br />

Legal Accountabilities continued<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Independently monitors and<br />

evaluates his or her own practice,<br />

professional development<br />

needs and goals, and need for<br />

clinical consultation/supervison<br />

• Develops, facilitates and<br />

implements learning activities<br />

to promote professional<br />

development of all interdisciplinary<br />

staff members<br />

• Provides constructive feedback<br />

and recognition of<br />

accomplishments to staff<br />

• Critically analyses program<br />

practice and makes recommendations<br />

at program and<br />

senior administration level for<br />

improvement<br />

• Leads team in evaluation of<br />

practice through research and<br />

application of current outcome<br />

measures and development<br />

of population-specific ones<br />

• Actively develops proposals<br />

for funding<br />

• Assumes responsibility for<br />

monitoring her or his own<br />

needs with respect to professional<br />

development and seeks<br />

out supervision and consultation<br />

as needed<br />

• Provides competent staff and<br />

students with feedback that<br />

encourages professional<br />

growth<br />

• Demonstrates mastery in<br />

evaluation of practice, utilization<br />

and dissemination of<br />

research<br />

• Engages in research by<br />

critiquing research reports<br />

• Takes leadership role in<br />

clinical research activities<br />

(e.g., literature searches,<br />

subject recruitment, pre /<br />

post testing, report writing)<br />

• Conducts internal and external<br />

presentations of clinical<br />

work and / or research<br />

• Identifies opportunities for<br />

continued professional development<br />

that correspond with<br />

personal career goals<br />

• Seeks out and receives clinical<br />

supervision on a regular basis<br />

consistent with the value of<br />

lifelong learning<br />

• Engages in reflective practice<br />

and completes annual selfevaluation<br />

(padr) with<br />

Program Manager and / or<br />

Program apn/apc/discipline<br />

Chief<br />

• Utilizes research and identifies<br />

research opportunities<br />

Professional Development and<br />

Research<br />


<strong>Clinical</strong> <strong>Supervision</strong> <strong>Handbook</strong> Core <strong>Clinical</strong> Practice Competencies<br />


Competent Proficient Expert<br />

• Participates in the ethical<br />

review of research ensuring<br />

that ethical guidelines are<br />

followed to protect research<br />

participants and investigators<br />

• Publishes papers in clinical<br />

and / or research journals<br />

and books<br />

Professional Development and<br />

Research continued<br />

• Acts as primary supervisor for<br />

Masters and PhD students<br />

and staff<br />

• Creates a context for staff to<br />

be offered supervision in a<br />

safe, respectful, non-judgmental<br />

manner (as •outlined<br />

in the camh <strong>Clinical</strong><br />

<strong>Supervision</strong> <strong>Handbook</strong>) as a<br />

means of improving clinical<br />

practice andclient outcomes<br />

• Provides supervision of supervision<br />

to clinical colleagues<br />

• May provide teaching and / or<br />

training to community partners<br />

universities<br />

Consultation and Education • Acts as a<br />

• Provides supervision of new<br />

preceptor/mentor/supervisor camh staff, undergraduates<br />

for students and new staff to and students from community<br />

support professional growth colleges<br />

• Respects and solicits interdis- • May provide teaching and / or<br />

ciplinary input into client and training to community part-<br />

family care<br />

ners and / or universities<br />


PG121<br />

A Pan American Health Organization /<br />

World Health Organization Collaborating Centre 3542/03-2008

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