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CLINICAL
SUPERVISION
HANDBOOK
A GUIDE FOR CLINICAL SUPERVISORS
FOR ADDICTION AND MENTAL HEALTH
The Office of Nursing Practice and Professional Services
(Centre for Addition and Mental Health) and
the Faculty of Social Work (University of Toronto)

CLINICAL
SUPERVISION
HANDBOOK
A GUIDE FOR CLINICAL SUPERVISORS
FOR ADDICTION AND MENTAL HEALTH

CLINICAL
SUPERVISION
HANDBOOK
A GUIDE FOR CLINICAL SUPERVISORS
FOR ADDICTION AND MENTAL HEALTH
The Office of Nursing Practice and Professional Services
(Centre for Addiction and Mental Health) and
the Faculty of Social Work (University of Toronto):
Kirstin Bindseil Regine King Kathy Ryan
Marion Bogo Kate Kitchen Rani Srivastava
Tim Godden Jane Paterson Lea Tufford
Marilyn Herie Maria Reyes
Eva Ingber Cheryl Rolin-Gilman
A Pan American Health Organization /
World Health Organization Collaborating Centre

Clinical Supervision Handbook
ISBN: 978-0-88868-725-8 (PRINT)
ISBN: 978-0-88868-726-5 (PDF)
ISBN: 978-0-88868-727-2 (HTML)
Product code PG121
Printed in Canada
Copyright © 2008 Centre for Addiction and Mental Health
Any or all parts of this publication may be reproduced or copied with acknowledgement,
without permission of the publisher. However, this publication may not be reproduced
and distributed for a fee without the specific, written authorization of the publisher.
This publication may be available in other formats. For information about
alternative formats or other camh publications, or to place an order, please contact
Sales and Distribution:
Toll-free: 1-800 661-1111
Toronto: 416 595-6059
E-mail: publications@camh.net
Website: www.camh.net
This book was produced by the following camh staff:
Editorial: Diana Ballon, Jacquelyn Waller-Vintar
Design: Nancy Leung
Print production: Christine Harris
3542/03-2008 PG121

Contents
v
ix
ix
ix
x
x
Contents
Introduction
Development of the Handbook
Perspectives on Clinical Supervision
Literature Review
Framework for Clinical Supervision
1 CONTEXT OF CLINICAL SUPERVISION
1 Models of clinical supervision
Social Work
Nursing
Common Elements
Components of Clinical Supervision Models
3 Clinical Supervision at camh
Practice Environment
Leadership
Clinical Supervision Principles
9 Components of Clinical Supervision
Roles
Supervisory Activities
11 Clinician Development
12 Supervisor Development
13 Clinical Supervision, Knowledge Translation and Evidence-Based Practice
Incorporating Evidence-Based Practice into Clinical Supervision
17 Cultural Competence and Clinical Supervision
Cultural Competence
Incorporating Cultural Competence into Clinical Supervision Practices
23 IMPLEMENTING CLINICAL SUPERVISION
23 Beginning Clinical Supervision
The Clinical Supervision Relationship and Contracting
When Clinical Supervision is at the Request of the Manager
Giving Feedback on Performance
Learning Styles
Learning Styles and Clinical Supervision
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Clinical Supervision Handbook
37 Ongoing Clinical Supervision
Methods Of Clinical Supervision
Cultural Competence and Diversity
Group Supervision
Individual Clinical Supervision
A Case Presentation Model for Clinical Supervision
Spontaneous Clinical Supervision: Clinical Supervisor as Lighthouse
71 SPECIAL ISSUES
71 Interdisciplinary Clinical Supervision
Strengths of the Clinical Staff
Staff Cultural Diversity and its Impact on Clinical Supervision
Context of Interdisciplinary Supervision
Interdisciplinary Supervision in Practice
75 Nursing and Clinical Supervision
Reflective Practice
Exploring Nurse’s Perceptions of Clinical Supervision
Practical Issues
Preparation
78 A Multi-Method Professional Development Approach in Daily Practice
Integrated Care and Building Capacity in the Schizophrenia Program
82 Ethical Considerations in Clinical Supervision
Standard of Care
Ethical Considerations: An Example
85 Evaluating Clinical Supervision
86 Core Competencies in Clinical Supervision
Benefits and Barriers to Effective Clinical Supervision
Evaluating Diversity Competence in Clinical Supervision
Clinical Supervisor Evaluation
Documentation of Supervision In Clinical Settings
103 APPENDIX 1
103 Conceptualization of Clinical Supervision: A Review of the Literature
Social Work
Nursing
Conclusion
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Contents
115 APPENDIX 2
115 Evalautions For a Clinical Supervision Group
PART A
PART B
117 APPENDIX 3
117 Clinical Supervision Contract
119 APPENDIX 4
119 Core Clinical Practice Competencies
Levels of Practice
Domains of Practice
vii

Introduction
This handbook is the result of a group of advanced practice nurses and clinicians
who function as clinical supervisors at the Centre for Addiction and Mental Health
(camh) using their collective experiences to articulate a model of clinical supervision
in this organization. It reflects the integration of clinical experience, practice
wisdom and contributions from contemporary literature and research. The literature
and research base informing this handbook is drawn primarily from the social work
and nursing fields, with some references to psychology and organizational change. A
comprehensive review and integration of the supervision literature from all allied
health disciplines is beyond the scope of this handbook; however, we hope that readers
from all disciplines will find relevant and practical tips and suggestions.
DEVELOPMENT OF THE HANDBOOK
We used a range of iterative and developmental activities to create the handbook.
Initially there was considerable reflection and discussion about the nature of clinical
supervision, the activities and processes that appeared to work, and the challenges
faced. Individuals or small groups volunteered to develop topics further.
Conceptual, practice and empirical literature about clinical supervision was reviewed
from the perspectives of social work, nursing, psychology and other relevant sources.
Further discussion of the material led to refinement of ideas and practices. The discussion
also revealed confusion and tension about the definition of clinical supervision
within an organization and about developing effective supervision practices.
PERSPECTIVES ON CLINICAL SUPERVISION
The development of the handbook was an inter-professional practice activity that
brought together a team of experienced social workers and nurses. The members of
the team share:
• a commitment to client-centred care
• a commitment to professional education and development
• a common vision as employees of camh.
Professions have their own distinct cultures, histories and practices. Terms such as
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Clinical Supervision Handbook
“supervision” therefore have different meanings for nurses than they do for social
workers. As the working group explored clinical supervision, it became apparent
that this concept and function is interrelated with ideas about:
• power, authority, accountability and autonomy of individuals, managers and
clinical supervisors
• decision making in groups and teams
• the perceived organizational conditions necessary for education and professional
development.
LITERATURE REVIEW
The review of the literature presents the diverse way these themes are conceptualized
and the similarities and differences between professions (see Appendix 1, p. xx). Even
within professions there are different models of clinical supervision with varying
emphasis on accountability, reflection, applying theory to practice, coaching and skill
development, and integration of evidence-based practice. Through dialogue, it also
became evident that individuals have different perspectives about the complex issues
related to clinical supervision based on their own educational and work experiences.
The handbook therefore merges concepts from diverse clinical disciplines, particularly
nursing and social work, to develop an approach to clinical supervision that respects and
builds on these traditions while providing guidance for the challenges of supervision
and practice in mental health and addiction in contemporary society.
FRAMEWORK FOR CLINICAL SUPERVISION
The framework for supervision (see p. xx) represents current conceptualizations and
can provide principles to guide the process of clinical supervision through its various
stages. The goal is to enhance the knowledge of our clinical supervisory staff and
delineate the standards of clinical supervision we provide at camh. Three interrelated
functions of clinical supervision identified in both the nursing and social literature
are discussed: administrative, educational and supportive (Kadushin, 1976; Kadushin
& Harkness, 2002; Proctor, 1986). Methods and competencies for supervisors are presented
along with a suggested evaluation method. Special issues in mental health and
inter-professional settings are also examined.
Since camh is a major teaching centre, it is important to note that the practice of
clinical supervision of staff is distinct from supervision of students. Clinical supervision
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Introduction
can involve complicated organizational dynamics, hierarchies of administrative
authority and multiple accountabilities (Tsui, 2005). Anyone who provides clinical
supervision must be skilled in these practices. In Clinical Supervision, we discuss the
ways in which a psychologically safe environment can be created so that complex
clinical dilemmas can be brought forward. We also examine the clinical supervisor’s
ability to provide clear and meaningful feedback and outline the parameters of clinical
supervision.
This handbook is a “work-in-progress” that will be expanded and further refined
over time. We will continue to address the challenges outlined above through further
consultation with clinical staff and colleagues in similar organizations. We welcome
your comments and suggestions.
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CONTEXT OF
CLINICAL SUPERVISION
Models of clinical supervision
The definition of supervision differs across settings and professions.
SOCIAL WORK
Social work literature reflects a long history of valuing clinical supervision as the
crucial vehicle for professional development of the social worker (see Appendix 1,
Conceptualization of clinical supervision: a review of the literature, p. 103). Supervision
in social work is essentially conceived as a method to ensure the organization’s
mandate is achieved through enhancing the supervisee’s*ability to provide effective
service. Through discussion of routine and complex clinical situations, clinicians are
better equipped to meet client needs, and that, in turn, contributes to improved
client outcomes.
NURSING
In the nursing literature there is less agreement on the definition of clinical supervision
(see Appendix 1, Conceptualization of Clinical Supervision: A Review of the Literature,
p. 107). Logistical realities of nursing—including time away from clients, rotating
shifts, 24-hour care and stringent time-oriented duties make the use of clinical
supervision challenging. It appears from this literature that clinical supervision
has often been viewed as an authoritarian and hierarchical activity that arises in
response to an error or indiscretion.
This is beginning to change. Jones (2005) reviewed research literature on clinical
supervision and credits Winstanley and White (2003) with the most comprehensive
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Clinical Supervision Handbook
definition: “[clinical supervision focuses] upon the provision of empathetic support
to improve therapeutic skills, the transmission of knowledge and the facilitation of
reflective practice. The participants have an opportunity to evaluate, reflect, and develop
their own clinical practice and provide a support system to one another” (p. 8).
COMMON ELEMENTS
A comparison of the social work and nursing literature on clinical supervision
reveals common elements in the approaches offered by Kadushin’s model of three
interrelated functions of social work supervision and one model in nursing, Proctor’s
three function-interactive model (see Appendix 1, p. 103). Both nursing and social
work agree that clinical supervision should be differentiated from, on one hand, an
exclusive focus on line management, and, on the other, a quasi-therapeutic approach,
although elements of each may be present at times in the process of supervision.
COMPONENTS OF CLINICAL SUPERVISION MODELS
Administrative/normative (managerial)
Kadushin uses the term administrative supervision to describe selecting and orienting
workers/clinicians, assigning cases, monitoring, reviewing and evaluating work;
serving as socializing agent; and advocating and buffering within the organization.
Proctor uses the terms normative or managerial to describe a function that promotes
and complies with organizational policies.
Educational/formative
Both professions’ models have an educational component. For Kadushin, education
encompasses activities that develop the professional capacity of supervisees, including
teaching knowledge and skills, and developing self-awareness (Barker, 1995;
Munson, 2002) through, for example, teaching, case consultation, facilitating learning
and growth. For Proctor, educational supervision addresses skill development
for evidence-based nursing practice.
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Clinical Supervision at camh
Supportive/restorative
Kadushin’s third component is supportive supervision. He sees this component as
helping workers to handle job-related stress by providing appropriate praise and
encouragement, normalizing work-related reactions, affirming strengths, and sharing
responsibility for difficult decisions. Proctor’s third component, restorative (also
referred to as pastoral), is similar. It is a support function that helps the nursing
practitioner to understand and manage the emotional stress of nursing practice.
Each of these components is seen as influencing each other and as producing more
effective services for clients when operating in concert.
Clinical Supervision at camh
At camh, we are committed to upholding the highest standards of clinical care and
practice and to supporting the best clinical practice, professional education and professional
development for our staff. We strive to be a workplace where people excel
in a culture that embraces diversity and encourages teamwork, quality improvement,
safety and respect. We have a rich inter-professional environment at camh with
approximately 1,500 clinical staff representing 16 professional disciplines. It is essential
that these clinicians be supported in the work they do and that they receive the
organizational support required for ongoing professional growth and development.
Clinical supervision has been identified as one of the most important factors in
determining job satisfaction and quality of service to clients (Tsui, 2005). We therefore
believe that it is important to establish standards for clinical supervision
practice. We also realize the vital role that clinical supervision plays in supporting
clinicians in adapting to change. Initiatives such as Concurrent Disorders Capacity
Building, Clinical Cultural Competence, Building a Culture of Safety, Family
Centred Care, and Implementing a Recovery Framework are examples of broadbased
initiatives at camh that are supported by clinicians. Front-line clinicians are
vital to the successful implementation of these initiatives and when operational
challenges are encountered, clinical supervision plays a crucial support role.
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Clinical Supervision Handbook
PRACTICE ENVIRONMENT
The practice environment must include multiple perspectives and interests.
Individual clinicians are accountable to clients, colleagues, organizations and regulatory
bodies. Organizations must ensure standards and delivery of high quality care.
External stakeholders may influence practice with advice on models of practice that
should be emphasized. Funders link resources to outcomes, and consumer and family
groups are now active partners in program planning and service delivery. As an
organization, we must acknowledge and accept differing—and at times opposing—
positions on issues related to practice. For instance, at times legal advice may in fact
differ from the practice advice from a regulatory body. It is our task to create a practice
environment that allows for the expression of divergent opinions with the goal of
resolving issues. Clinical practice dilemmas and errors are a fact of life; it is the
response that counts. A culture of blame, over-regulation and punitive responses
will deter disclosure. Opportunities to identify the underlying conditions that led
to those clinical dilemmas and errors will be lost unless processes for review and
reflection are established to allow disclosure and discussion of difficult issues. Thus
clinical supervision has a dual focus: clinician development; and improved care and
enhanced health for our clients.
At camh, the desired practice environment includes:
• clinicians practicing ongoing critical self-appraisal
• an openness to the opinions and input of the client, and the work of the clinical
supervisor
• honest communication
• clear and regular documentation
• clinical practice that actively explores, examines and contributes to the evidencebase
for care and support
• an acknowledgement of the complexities of clinical practice
• empowerment of clients, families and communities
• active and ongoing dialogue among employees at all levels.
The process of clinical supervision is integral to the realization of these goals.
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Clinical Supervision at camh
LEADERSHIP
The clinical discipline chiefs, the advanced practice group and the clinical leadership
in the program areas have primary responsibility for development of professional
knowledge and skills. The discipline chiefs and the advanced practice group are in
many ways more similar than different in the roles and functions they perform in
the organization. The roles of both groups comprise five interrelated domains:
• practice
• consultation
• education
• research and scholarship
• leadership.
Perhaps the greatest difference between the two groups is that the discipline chiefs
are senior clinicians who lead the entire professional discipline across the organization
and are responsible for ensuring that professional practice standards are
adhered to across camh. The Advanced Practice Nurses or Clinicians (apn/c), also
senior clinicians, work directly in the clinical programs and supervise clinicians
from various disciplines. Members of the discipline chiefs, program clinical leadership
and the advanced practice groups can all have a role in the clinical supervision
of staff. It is important that those responsible for front-line staff be skilled in the area
of clinical supervision in order that job achievement be recognized and acknowledged.
CLINICAL SUPERVISION PRINCIPLES
Clinical supervision at camh is guided by the following interrelated principles:
• organization context and its crucial impact on the nature and quality of clinical
supervision
• improved client outcomes
• accountability
• advancement of clinicians’ specialized knowledge, skill and use of evidence-based
practice
• learning and professional development.
These principles support the organization’s goals of improved client-centred
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Clinical Supervision Handbook
care; enhanced health and client safety; and support, growth and retention of the
best professional staff.
Organizational context
Clinical supervision occurs within the organizational context and will be customized
in response to the unique characteristics of a particular clinical program area.
Organizations that value and promote clinical supervision as both an educational
process for clinicians and as a way to enhance accountability achieve greater employee
satisfaction and improved client outcomes.
Two overarching organizational themes characterize camh: a unionized environment
and clientele divided between inpatient and outpatient services. The hierarchical
environment of a unionized setting places the responsibility for clinical supervision
on those at the managerial level. All clinicians require high-quality clinical supervision
to meet their challenges and need for ongoing support. As an organization,
it is important that we find ways to provide clinical supervision to staff that work
shifts in the inpatient and residential areas at times when managers and clinical
supervisors may not be readily available to provide consultation.
When two or more hospitals merge to form a new organization, the organizational
culture often differs from that of its founding organizations. This may affect the
availability, perception and experience of clinical supervision. It takes time to develop
a shared perspective on the nature and process of clinical supervision. Any organization
comprises many departments, disciplines and individuals with a range of working
styles that contribute to its overall rhythm and achievements. Clinical supervision
requirements will vary with the unique program, culture, team members and learning
styles of its participants and so must be tailored accordingly. For example, when
camh was formed, there wasn’t a consistent practice of clinical supervision across
the entire organization. Although it was agreed that clinical supervision is integral to
clinical practice, it was necessary to redefine clinical supervision in this new culture.
Improved client outcomes
One of the aims of clinical supervision is the improvement of client outcomes. Given
the breadth of service at camh outcomes are not the same for all clients but fluctuate
to accommodate client needs and challenges. Increasingly, we experience greater
complexity in the client populations we treat.
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Clinical Supervision at camh
Accountability
The supervisory relationship entails accountability within a supportive and educational
framework. By virtue of their role in the organization, clinical supervisors,
along with the staff they supervise, have accountability for client outcomes. Also, the
clinical supervisor is responsible for monitoring the clinical performance of staff.
The accountability demands on health care organizations are generally steep and the
clinical supervisor needs to account for client and worker outcomes. It is challenging
for the supervisor to balance the two functions of support and accountability. People
engaged in clinical supervision need to discuss this duality from the outset. It also
challenges more traditional notions of clinical supervision, where a clinician would
be assured of almost complete confidentiality in processing cases with the clinical
supervisor.
Specialized knowledge, skill and use
of evidence-based practice
The following summarizes the generic competency required of all camh clinical staff
regardless of professional discipline:
• clinician-client relationship
• family and social support
• professional autonomy and accountability
• professional development and research
• assessment and monitoring
• interviewing, formulation and documentation
• treatment planning
• therapeutic interventions
• anticipating and responding to rapidly changing clinical situations
• evaluation of care
• teaching, coaching and empowering
• teamwork, collaboration and partnerships
• ethical, organizational and legal accountabilities
• consultation and education
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Clinical Supervision Handbook
For a description of the requirements for each of these domains, see Appendix 4,
p. 119.
As well as generic competencies, all clinicians are expected to have specialized
knowledge and clinical skills associated with the clinician’s program.
Professional development
Professional development within one’s discipline flows from a commitment to lifelong
learning: clinical supervision is one method for achieving this goal. Regulated
health professionals are members of regulatory bodies with annual educational
requirements and standards of practice and ethical conduct. Unregulated clinicians
who are members of professional associations often must meet educational objectives
to qualify for, and maintain, membership. Clinical supervision can help clinicians
stay abreast of developments in their field.
Educational and clinical supervisory opportunities may be provided in ones’ place
of employment. Many professionals participate in external educational activities such
as courses, workshops or private consultation. In organizationally offered clinical
supervision, clinicians demonstrate their commitment to ongoing learning and show
accountability to the process through their willingness to learn, their interest in
developing their clinical skills and being open to receiving support and being challenged.
Through the formation of a partnership for learning, clinical supervisors
and clinicians agree to journey together toward both the development of clinicians
as learners and as members of their colleges.
8

Components of Clinical Supervision
Components of Clinical Supervision
ROLES
Clinician
In clinical supervision, clinicians can achieve a higher level of expertise in their
discipline and/or specialized area of practice. A hallmark of clinical supervision is
the opportunity to reflect on one’s own practice, to gain others’ opinions and hence
develop a more accurate self-appraisal and, through discussion, to draw the links
between theory and practice.
Clinical supervisors and clinicians work together to develop and maintain productive,
goal-oriented supervision. They negotiate the framework in which clinical supervision
is carried out, including establishing the frequency of meetings, avoiding outside
interference and being prompt. Clinicians define their own learning goals. The goals
often arise from the case examples they select. These goals can be met through learning
from supervision and from activities clinicians undertake beyond the supervisory
session. Clinicians prepare for clinical supervision by having an agenda and information
pertinent to the case or to clinical dilemmas. Information can include case notes,
segments of tapes, a care plan and case questions. Case material should represent
challenges and difficulties as well as successes. By choosing to discuss cases where they
have encountered difficulties, clinicians demonstrate their willingness to take risks
and learn from others. The learning process involves dialogue, openness to in-depth
reflection on practice, and receiving both challenging and supportive feedback. The
clinician records the supervisor’s recommendations and the actions or outcomes he
or she has taken as a result of clinical supervision in the outpatients’ progress notes
and in the interdisciplinary plan of inpatients.
Clinicians are active participants in clinical supervision and give feedback to the
supervisor so they can jointly evaluate the process in relation to the verbal or written
supervision contract. Contracting at regular intervals allows the clinician to discuss
learning goals, and the clinical supervision process, and to adjust the contract as
necessary. It is the responsibility of the clinician to apply what he or she has learnt
with clients. Self-evaluation is imperative and allows clinicians to determine when
learning goals are met and when the clinician is ready for a more active or autonomous
role with clients, such as in leading a group.
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Clinical Supervision Handbook
Learning is not relegated to the confines of the supervision session. The clinician
and clinical supervisor, working together, must negotiate and agree on the expectations
for learning between sessions. Activities may include reading, viewing videos
and writing process recordings or detailed notes of sessions.
Clinical supervisor
Clinical supervisors demonstrate substantive or content knowledge in multiple
domains through discussion of clinical issues, examination of organizational development
and inter-professional practice. The ability to work with the content of
multiple domains engenders confidence in supervisory skills. Clinical supervisors’
credibility, based on formal education and depth of experience, is an important
contributor to the supervisor-clinician relationship. Another factor is the availability
of clinical supervisors for both scheduled and unscheduled supervision, since concerns
related to clients also arise beyond the usual hours of the working day. Good
clinical supervisors recognize and value diverse perspectives. They also acknowledge
the clinician’s previous work experiences. These factors contribute to a rich, heterogeneous
work environment.
Shared responsibility
The supervisor and the clinician share responsibility for creating a safe environment
for clinical supervision. Safe environments are characterized by respect, openness,
support, trust and the provision of non-judgmental feedback. The establishment
of a safe environment allows creativity to flourish when dealing with challenging
situations and expands the possibilities of service delivery.
Power and authority
The hierarchical aspect of the supervisor-clinician relationship can lead to conflict,
stress and tension. Effective clinical supervisors don’t ignore the inevitable power
dynamics. Instead they model a parallel process of journeying together. Supervision
experts note as crucial the ability to exercise supervisory responsibility in a respectful,
fair and objective manner and to purposefully avoid the abuse of power (Centre
for Substance Abuse Treatment, 2007).
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Clinician Development
SUPERVISORY ACTIVITIES
Clinicians come to clinical supervision with a diverse array of learning styles, such
that the adage “one size fits all” doesn’t apply. Recognizing and then adapting
teaching to match the learning styles of clinicians is a critical supervisory skill
(see Learning styles, p. 33). Observation, discussion, feedback, role play, coaching,
demonstrating and questioning are examples of supervisory activities. Supervisors
need to master each of these so they can customize learning activities to meet the
needs of all the clinicians with whom they are working.
Conceptual frameworks that link theory to practice that’s relevant to camh clients
help clinicians’ work to progress in an intentional and planned manner. Reflection
encourages and provides the opportunity for clinicians to consider their experiences
in practice, explore feelings invoked through working with clients, and understand
the meanings they give to interactions. This process allows clinicians to arrive at
more mindful and deliberate subsequent interventions. Critical self-reflection and
self-inquiry helps clinicians recognize their strength and growth areas.
Clinician Development
Clinicians pass through stages in their careers. In the early stages of their careers, or
when they join a new organization, clinicians may benefit from increased support,
education and clinical supervision as they orient themselves to the organizational
environment and clientele. Later career professionals may require less clinical supervision
and more focused case consultation.
Most professionals are educated in their specific disciplines, and while in training
may have little opportunity to collaborate with other disciplines. However, in health
care organizations, they are expected to participate in teamwork and collaborative
practice. There is an increasing number of inter-professional education initiatives
that recognize the knowledge base required to practice collaboratively. The curricula
of the health care disciplines are evolving so that students will have the opportunity
for curriculum and practicum experiences in collaborative practice.
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Clinical Supervision Handbook
The optimization of holistic clinical care first requires clinicians to be well grounded
in their own professional discipline. It is a challenge for a junior clinician to maintain
this professional identity and assert the unique perspective of the discipline within
the interdisciplinary team. Without the opportunity for regular clinical supervision
and reflection on their unique roles in teams, junior clinicians can risk aligning
themselves with the power base on a team, thus silencing the unique perspective of
their discipline. The clinical supervisor therefore must consider the career stage of the
clinician in choosing pertinent material and issues for supervisory sessions.
Supervisor Development
Clinical supervisors, similar to clinicians, engage in professional development in
their various roles. Reflection on their practice as clinicians and as supervisors allows
them the opportunity to examine themselves from cognitive, affective and behavioural
angles. By acknowledging strength areas and challenging inherent assumptions
and ineffective patterns, clinical supervisors deepen their level of service offered to
both clients and clinicians and are able to seek their own supervision as required.
Professional development may also result in further expertise in a clinical issue or
exploration of a new area. Clinical supervisors are in an excellent position to provide
leadership with respect to evidence-based practice through staying abreast of the
most current literature and introducing new concepts, practices and guidelines in
their supervisory meetings with clinicians. Continuous learning refreshes clinical
processes, allows clinical supervisors to remain current and promotes a similar
commitment on the part of clinicians.
The processes of transference and countertransference are two of the inevitable
by-products of working in helping professions. Effective clinical supervisors understand
the dynamics of these two processes both between client and clinician and
between clinician and clinical supervisor. Clinical supervisors facilitate clinicians’
understanding of how these dynamics impact on clinical work. At the same time,
clinical supervisors reflect on their personal transference and countertransference
issues to promote their development.
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Clinical Supervision, Knowledge Translation and Evidence-Based Practice
Clinical Supervision,
Knowledge Translation
and Evidence-Based Practice
Organizations of all sizes are increasingly concerned that clinical practice be based
on research where possible. The rise of “best practice” documents and guidelines
attests to the urgency of bridging the gap between research and practice and reflects
the reality that most clinicians do not read—let alone incorporate—scientific findings
and practice protocol. Funders, consumer groups, researchers and agency/program
management have all identified “knowledge translation” as a major challenge.
Knowledge translation has been defined by the Canadian Institutes of Health Research
(cihr) as “the exchange, synthesis and ethically-sound application of research findings
within a complex system of relationships among researchers and users.” There is a
growing body of literature on the topic of knowledge translation relevant to health
care. The notion that clinical decisions should be made based on evidence-based
practices and systematic review has become widely accepted (Zwarenstein & Reeves,
2006). It is also well recognized that the results of research are unevenly adopted in
clinical practice (Haines, 1998). The process of translation does not happen on an
immediate or consistent basis because of the varying characteristics of adopters
(i.e., practitioners). For example, Rogers (1983) suggests that innovations are picked
up first by innovators and early adopters—the “champions” of practice innovations—
followed by the early majority, the late majority and the small group of late adopters
or “laggards.” In recognition of the challenges of transferring and adapting research
findings to clinical practice, attention has been focused on understanding factors
affecting the transfer of knowledge.
Reviews of knowledge transfer literature have suggested that the failure of collaboration
and communication between health care professionals has a profoundly negative
effect within the health care system (Kerner et al., 2005; Zwarenstein & Reeves, 2006).
To address this issue, it is important to design a clinical supervision process that
accommodates the needs of the many professions and disciplines in the health care
system, and to develop good inter-professional collaboration.
One of the most common strategies in enhancing or incorporating evidence-based
practice has been through clinically focused, continuing education workshops.
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Clinical Supervision Handbook
However, research has shown that clinical practice is minimally influenced by training
alone (see Miller et al., 2006 for a review of this research.) In fact, Miller et al. (2006)
point out that “[s]elf-reports of competence . ..bear little or no relationship to
actual behavioural proficiency in delivering a treatment” (p. 32). On the other hand,
there is some evidence that clinical training combined with ongoing feedback and
coaching (such as that provided through supervision) can yield significant improvement
(Miller et al., 2006).
Clinical supervision is, therefore, critical for promoting the use of evidence-based
models and tools, as well as an effective means of disseminating these approaches.
As Miller and colleagues (2006) state, “The dissemination of knowledge-focused
material and workshops cannot substitute for proper clinical training, feedback and
supervision in helping providers learn more effective ebt [Evidence-Based Treatments]”
(p.35, emphasis added). Given the importance of offering—and having clinicians
adhere to—evidence-based treatment models, knowledge translation should be a
major focus of clinical supervisors’ work.
INCORPORATING EVIDENCE-BASED
PRACTICE INTO CLINICAL SUPERVISION
Ongoing feedback and coaching are critical in helping clinicians to implement
evidence-based practice applications and treatment protocols. Clinical supervision
is an obvious and ideal context for this to occur. A number of important elements
are prerequisites:
• Clinical supervisors and clinicians understand and are committed to evidencebased
practice approaches.
• The clinical supervisor has expertise in the evidence-based methods in which
clinicians are practising.
• There are opportunities for observation and practice of clinicians’ clinical
interactions during supervision sessions.
• Clinical supervisors provide corrective feedback that is experienced by clinicians
as constructive, relevant and credible.
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Clinical Supervision, Knowledge Translation and Evidence-Based Practice
Commitment to evidence-based practice
The implementation of evidence-based approaches is not without controversy
among human service practitioners, and has been criticized on the grounds that
it privileges empiricism over other dimensions and sources of wisdom, such as
qualitative research, practice wisdom, consumer perspectives, cultural considerations
and situational context (Petr & Walter, 2005). This perspective, however, doesn’t
acknowledge the ways in which our understanding of evidence-based practice has
evolved. For example, Petr and Walter discuss how, in the social work field, the
rise of empirically based practice in the late 1980s emphasized clinical practice
based primarily on scientific expertise. By the mid-1990s this notion broadened
to consider the appropriateness of research applications to individual situations,
ethical issues, and client values and expectations. Current conceptualizations refer
to “evidence-based practice wisdom,” with an appreciation of multiple sources
of “evidence” applied in a value-critical approach. It may be necessary for clinical
supervisors to discuss clinicians’ understanding of evidence-based practice, and
to explore how clinicians apply advances in scientific knowledge and integrate
these with other knowledge sources.
Supervisor expertise
In the supervision context, “expertise” means more than one’s ability to demonstrate
advanced proficiency in evidence-based treatment protocols. Supervision requires
a deep, critical understanding of the theoretical, research and practice dimensions
of these treatment approaches, as well as an ability to deconstruct these approaches
into concrete, practical applications. As an analogy, not all outstanding athletes are
successful coaches: applying skills is different from teaching and supporting skill
development in others. There is a large literature related to adult education and
training that is beyond the scope of this handbook. However, Renner (1999) provides
a summary of adult learning theory and practice that is concise yet comprehensive.
Opportunities for observation and practice
Clinical supervisors need to resist the temptation to use clinical supervision time
primarily for discussing cases and dispensing advice. Learning by doing, or active
learning (based on the learning theory known as constructivism), has become the
hallmark of current approaches to teaching and learning (Tight, 1996). Examples
of incorporating active learning into supervision might include:
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Clinical Supervision Handbook
• role-playing a challenging case example with the clinician
• live observation and feedback of a clinical consultation
• practising a discrete skill (such as complex reflections in motivational interventions)
with clinicians
• playing a video recording of a session with frequent pauses for critical, reflective
commentary by the clinician and/or clinical supervisor/group.
• In all of the above examples, clinical skills are examined in the context of the
evidence-based treatment application being applied or demonstrated.
Psychological safety and constructive feedback
Demonstrating skills in front of clinical supervisors and peers is often experienced
as “high-risk” by clinicians, and demands that clinical supervisors convey collegial
respect, positive regard and non-judgmental acceptance. Fostering a positive learning
climate can be better accomplished when clinical supervisors model their willingness
to take risks and are transparent about the areas they need to further develop. For
example, the clinical supervisor could first demonstrate practice activities before
asking clinicians to do so. In addition, feedback is generally experienced as more
constructive and salient when it is neutral, concrete and references the skills or
philosophy underlying the clinical approach.
In summary, advancing skills development in evidence-based practice approaches
means that clinical supervisors must:
• facilitate a shared understanding and appreciation of the meaning of evidencebased
practice
• be proficient in supporting clinicians to learn evidence-based approaches and
apply these approaches to practice
• apply and critique concrete strategies and tools in a safe and supportive learning
context.
16

Cultural Competence and Clinical Supervision
Cultural Competence and
Clinical Supervision
The diverse, multicultural makeup of our society means we must carefully consider
issues of race, culture and other dimensions of diversity. Developing cultural competence
is now “a recognized requirement for achieving professional standards in therapy
and supervision training” (Divac & Heaphy, 2005, p. 282). The need for cultural
competence in mental health practice has been described as a professional as well as
a moral and ethical imperative. As noted by Sue and colleagues:
White culture is such a dominant norm that it acts as an invisible veil
that prevents people from seeing counseling as a potentially biased
system.…What is needed is for counselors to become culturally aware,
to act on the basis of a critical analysis and understanding of their
own conditioning, the conditioning of their clients, and the sociopolitical
system of which they are both a part. Without such awareness,
the counselor who works with a culturally different [sic] client may
be engaging in cultural oppression using unethical and harmful
practices. (Sue et al., 1992, p.72-73)
CULTURAL COMPETENCE
The term cultural competence was first defined by mental health researchers over a
decade ago as “a set of congruent behaviors, attitudes, and policies that come together in
a system, agency, or amongst professionals and enables that system, agency or those
professionals to work effectively in cross cultural situations”(Cross et al., 1989 p. iv).
In this definition “culture” refers to integrated patterns of human behaviour that
include the language, thoughts, communications, actions, customs, beliefs and values
of racial, ethnic, religious or social groups. Culture should not be conceptualized
narrowly in terms of only race, ethnicity, and country of origin; instead, culture must
be defined broadly as inclusive of various diversity dimensions including, but not
limited to, age, gender, gender identity, sexual orientation and socio-economic status.
“Competence” implies having the capacity to function effectively as an individual
and an organization within the context of the cultural beliefs, behaviours and needs
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presented by the clients, consumers and their communities (Cross et al., 1989). Thus
cultural competence is differentiated from cultural sensitivity and awareness by a
need for action and altering practices to effectively interact with different cultural
groups. (cdc National Prevention Information Network, n.d). Cultural competence
in clinical care encompasses an understanding of the other’s worldview, a critical
understanding of the dynamics of power and social location in our society, and the
ability to adapt one’s practice accordingly (camh Diversity Programs Office, 2003).
There are many frameworks and models of cultural competence across the various
disciplines. A critical examination of the literature, however, reveals remarkable similarity
in the requisite competencies. The differences are more in the area of emphasis
(Haarmans, 2004). There is general agreement that clinical cultural competence
comprises three domains as described by Sue and colleagues:
• awareness of attitudes, values and biases (affective domain)
• knowledge (cognitive domain)
• skills required to be effective in cross-cultural encounters (behavioural domain).
In addition, a fourth dimension of power/relationships has also emerged as an
important domain for consideration (cno, 2003; Sandowsky et al., 1994). This
domain refers to the dynamics inherent in a clinician-client relationship with similar
and different cultural values, racial identity attitudes and issues of power, control,
and oppression (Haarmans, 2004). For a more comprehensive discussion of clinical
cultural competence, see Haarmans.
Development of cultural competence is generally recognized as a process that evolves
with time, experience and deliberate attention. As such, cultural competence is often
described on a continuum, with one end reflecting little recognition of the need for
incorporating culture into care, and the other end where cultural knowledge and
insight lead to innovative practices and positive outcomes for the client, the clinician
and the health care organization (Cross et al., 1989; Tripp-Reimer et al., 2001).
Although much has been written on the need to develop cultural awareness, skills
and knowledge to provide clinical supervision (D’Andrea & Daniels, 1997; Sue, 1991),
little information is available on how to imbed and develop cultural competence
within clinical supervision (Leong & Wagner, 1994; Johnson, 1987). The lack of an
operationalized definition for clinical cultural competence (ccc) and a corresponding
lack of validated, comprehensive measures needed for training and research are
major impediments to the development of cultural competence (Lo & Fung, 2003).
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Cultural Competence and Clinical Supervision
INCORPORATING CULTURAL COMPETENCE INTO
CLINICAL SUPERVISION PRACTICES
Within the supervision process, the need for cultural competence is evident at two
distinct, but inter-related levels. These are:
• developing a clinician’s capacity in cultural competence
• addressing the dynamics of culture and difference within the superviseesupervisor
relationship.
The supervision process is an effective vehicle for assessing a clinician’s multicultural
competence and further developing cultural awareness, knowledge and skills. It has been
described as an effective process for examining the conscious and the unconscious
pathologizing of clients and therapists (Tummala-Narra, 2004). Raising cultural
issues encourages self-exploration and can be “eye opening,” leading to development
of new perspectives and practices (Cashwell et. al., 1997). Supervisors need to develop
strategies that move supervisees from knowing that cultural differences exist
(cultural sensitivity) to knowing how to work with individuals from diverse groups
(cultural competence) (Cashwell et al., 1997). To support this journey, intellectual
understanding needs to be augmented by actual examples from practice. An understanding
of how our own gender, race, ethnicity, religion, socioeconomic class,
generation and geographical region shape our sense of self can result in increased
appreciation of how others are shaped by the same variables (Okun et al., 1999).
Power dynamics
The challenges of cultural dynamics are not limited to work with clients; they apply
equally to the process of supervision itself and the supervisor-supervisee relationship.
Research examining the experiences of supervisees of colour highlights the
perception that the supervisors’ clinical approaches are often “rooted in a limited,
dominant culture perspective, despite their good intentions to attend to issues of
difference” (Tumala-Narra, 2004, p. 304). In some instances, supervisors may minimize
racially or culturally relevant material, either because of a lack of knowledge, or due
to fear of being perceived as a racist. Supervisors who expect themselves to be “all
knowing” can feel threatened by the client’s or the supervisee’s cultural knowledge.
However, such supervisory encounters perpetuate racial enactments and can be
silencing for the therapist and the client (Tummala-Narra, 2004).
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Another emotion that can impede the supervision encounter is shame. Lybarger
(2001) describes three progressively deeper levels of shame: embarrassment, humiliation
and mortification. Embarrassment is associated with feeling self-conscious, ill
at ease, disconcerted or flustered; humiliation occurs when there is a perceived loss
of pride or dignity and mortification occurs when humiliation is deep and is associated
with feelings of helplessness, hopelessness and despair. Tummala-Nala suggests
that the lack of supervisor initiative to explore issues of diversity can contribute to
lowered self-esteem and the experience of shame, which in turn may trigger defensive
reactions such as avoidance and withdrawal on the part of the supervisee. Although
it is important to explore diversity issues in the supervisory encounter, it needs to be
done with an awareness that racial discourses continue to be highly emotional and
can lead to feelings of vulnerability. For these reasons it is critical to determine the
extent to which the supervisory relationship is a safe space for exploration of such
issues (Tummala-Nala, 2004).
Supervisory competencies and
strategies for addressing diversity
While there is no one approach to developing cultural competence for clinical supervision,
there are a variety of methods that can assist supervisors. It is critical that
supervisors “walk the talk.” The walk is a journey that enhances personal growth and
identity development. “Culturally skilled counselors are constantly seeking to understand
themselves as racial and cultural beings and are actively seeking a nonracist identity”
(Pedersen, 2000, p. 20). The cultural awareness and skill development of clinical staff
is often dependent upon clinical supervisors who consistently model behaviour that
is reflective and acknowledges the power held in a supervisory relationship.
Clinical supervisors are in the unique position to be mentors, teachers, supporters
and evaluators. This unique relationship of supervisor-supervisee is markedly different
than the relationship staff members form with a client (Baird, 1999). Culturally
competent supervisors are able to understand and put into perspective the worldviews
of their diverse supervisees and clients and reflect the experience to the staff.
During supervision they are able to create a positive environment where there is
an opportunity for staff members to address and discuss issues that may be related
to culture in an open and explicit manner (D’Andrea & Daniels, 1997). Culturally
competent supervisors have the ability to work across cultures and work with clinical
staff to do the same.
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Cultural Competence and Clinical Supervision
Supervisors can influence clinicians by helping them investigate ways to maintain
language competency while communicating or when trying to understand the
diverse communication styles of their clients. In supervision, they can share valid
and reliable assessment tools and techniques (Gopaul-McNicol, 2001; Paniagua, 1998).
Supervisors can also use a variety of strategies to address issues of diversity, race and
culture. However, a willingness to engage in ongoing self-examination and an openness
to new and unknown information are foundational requisites for these strategies
(Tummala-Narra, 2004). Some approaches to develop cultural competence include
role play, interpersonal process recall, first person feedback and metaphor (for a
detailed discussion see Cashwell et al., 1997; Divac & Heaphy, 2005; Hernandez, 2003).
Tummala–Narra (2004) describes four strategies that can be utilized by supervisors:
• increasing cultural knowledge
• initiating the discussion of race and culture
• attending to transferential responses
• engaging in multicultural education.
Although no individual is expected to have detailed knowledge about every cultural
group, it is important for supervisors to attain a “reasonable” level of cultural awareness,
knowledge and range of communication skills in order to model these to their supervisees
(Garret et al., 2001). This generic cultural knowledge includes knowledge of:
• institutional barriers that prevent some clients from using mental health services
• history, experience and consequences of oppression, prejudice, discrimination,
racism and structural inequalities
• the heterogeneity that exists within and across cultural groups and the need to
avoid overgeneralization and negative stereotyping (Haarmans, 2004).
While it may be important at times for the supervisor to ask the supervisee about
issues pertinent to a particular cultural group (or for the therapist to ask a client),
such inquiries should not be considered sufficient to serve as a knowledge base that
guides supervision or psychotherapeutic interventions (Tummala-Narra, 2004).
Supervisors and clinicians need to make a commitment to acquire such knowledge
as part of their ongoing learning, and use the supervisee or client to validate the
issues pertinent to them as members of particular groups.
Initiating discussion of cultural and diversity issues is another recommended strategy.
Such initiation by the supervisor recognizes the power dynamics of the relationship
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and challenges the traditional notion of neutrality and normalizing the complexity
associated with diversity (Tummala-Narra, 2004). It is important for supervisors to
create a safe environment where such discussions can occur openly and without the
experience of shame. Such discussions can also highlight communication barriers that
may be rooted in cultural differences that need to be addressed (Garrett et al., 2001).
Encounters between clients, supervisees and supervisors from different cultures
involve a set of interconnected transference reactions (Tummala-Narra, 2004, p. 309).
These reactions may be based on individual characteristics as well as characteristics
associated with particular racial or cultural groups. In reflecting on transferential
responses it is important to critically reflect on one’s own assumptions and traditional
views. It is also important to consider the ways in which racial and cultural
identity shapes social and psychic realities and interpretations. Such a stance will
minimize avoidance and treatment of cultural issues as “extraneous” or “exotic”
(Tummala-Narra, 2004).
Lastly, it is important for supervisors to engage in ongoing education on multicultural
perspectives as they relate to psychopathology and therapy. Research indicates a
strong link between self-rated competence and the number of diverse clients seen by
the therapist, suggesting that treating diverse client groups is an important training
experience (Allison et al., 1996). It is also important for supervisors to seek out literature
and engage in discussions on race, culture and mental health. Such exploration
and reflection will assist the supervisor and the supervisee in understanding the
complexities of culture and its relationship to mental health and mental illness.
In summary, the rapidly changing demographics of clients require increased attention
to culture and the supervisory relationship. The tools for ensuring supervisees’ cultural
competence are within reach and require a commitment from each one of us as
clinicians and as supervisors. Cultural competence is a critical skill for both individual
and group supervision and can be developed through a variety of experiential
learning approaches. Integral to this process is reflection on such issues as power
dynamics, divergence of world views and stereotyping.
22

IMPLEMENTING
CLINICAL SUPERVISION
Beginning Clinical Supervision
THE CLINICAL SUPERVISION RELATIONSHIP
AND CONTRACTING
As you begins to meet with clinicians, it is useful to identify what one already knows
about clinical supervision, what the program leadership hopes to obtain from clinical
supervision and what the clinician knows about and expects from the clinical supervision
process. This is an opportunity to develop relationships and clarify expectations.
In the process of contracting, you can begin to provide a foundation for the clinical
supervisory relationship. Although this is useful to do at the beginning, it is important
to remember that relationship clarification and contracting will likely occur throughout
the clinical supervisory process.
Shulman (1993) identifies four main areas of contracting as you develop relationships
in the beginning phase of a clinical supervisory situation:
• share the sense of purpose
• describe the clinical supervisor’s role
• elicit feedback from the clinician on his or her perceptions of clinical supervision
• discuss mutual obligations and expectations related to the clinical supervisor’s
authority.
Sense of purpose
The clinical supervisor should discuss the purpose and expectations of clinical
supervision with the clinician. A shared purpose offers clarity about the clinical
supervisory process for the program staff, the clinical supervisor and clinician. You
should discuss several definitions of clinical supervision with the program and
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Clinical Supervision Handbook
clinician to learn how the program staff will use the clinical supervision process in
day-to-day work.
Clinical supervisor’s role
As programs and services in health care evolve, new leadership roles (e.g., discipline
chiefs and advanced practice clinicians / nurses) have been created to carry out the
functions of clinical supervision and support of staff. There is a growing recognition
that these roles are distinct from that of the manager in that the manager is the individual
responsible for the administrative functions of the program. These leadership
roles of clinical supervisor and manager have many areas of shared responsibility
such as program development and the facilitation of team processes. The challenge
for people in these roles is to navigate the boundary between performance management
and clinical supervision. The challenge is to deliver supervision that provides
enough of a safe space for front-line staff to explore practice issues, while at the same
time making sure that administrative managers feel adequately informed about matters
under their purview.
Elicit feedback from the clinician
A discussion about perceptions, beliefs and attitudes about clinical supervision can
help to demystify the process. A discussion of how the clinician felt about her or his
last clinical supervisor or the clinical supervision model can help to clarify present
expectations and allow constructive feedback. This is an opportunity to begin to
develop trust and understanding with the clinician.
Discuss mutual obligations and expectations related to
authority
Although clinical supervisors may be uncomfortable with discussing authority, they
should discuss the balance between their supervisory and managerial roles with
every one they supervise as soon as possible in the supervision relationship. Many
clinicians are concerned about when information will be shared with management
and if the information will be included in a performance review. For example: Will
the manager attend some of the sessions? Will management receive reports about
the clinical supervision sessions? It is important to be clear about expectations,
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Beginning Clinical Supervision
procedures and roles so that clinicians can develop a clear understanding of the
parameters of the clinical supervision process.
Dealing with suboptimal standards of practice
What are the clinical supervisors’ obligations once they have become aware of
suboptimal standards of practice?
To answer this question, we need to consider at least two scenarios:
• when issues arise spontaneously in supervision
• when issues are generated from performance management and supervision.
When issues arise spontaneously in supervision
A well-functioning supervision relationship can resolve many challenges. A good
general rule is that a practice issue identified in supervision sessions can remain
within the confines of supervision as long as the client’s care has not been seriously
compromised and the supervision process is yielding results. If either of these
conditions were not met, the clinical supervisor would need to consult with the
manager. For example:
• When clients complain about inappropriate staff behaviour, the manager should
be informed and directly involved in the plan to follow up on the complaint,
since the event could lead to disciplinary action. The clinical supervisor’s role
can be to follow up with the areas of concern highlighted by the complaint and
to monitor the staff member’s progress in the hope that he or she does not repeat
the inappropriate behaviour.
• If the clinician and the clinical supervisor don’t agree that the clinician’s behaviour
is a concern, then the clinical supervisor should inform the manager and all could
decide together how to proceed.
• If the clinical supervisor learns at any time that a clinician has broken the code
of conduct of the organization or has violated the code of ethics as established by
the clinician’s regulatory body, then the manager must be informed.
Even when the clinical supervisor takes an issue outside the confines of clinical
supervision, the consultation with the manager can be considered a resource to help
to resolve a problem that may not require performance management and discipline.
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When issues are generated from performance management processes
Any clinical supervision task generated by the performance management system
should include the following:
• a precise description of what aspect of the staff member’s practice is below standard
• a precise description of how a staff member’s practice has to change in order to
meet expectations
• a precise plan outlining what kind of documentation will be required from the
clinician to monitor performance
• the maximum length of time available for achieving the task at hand
• details on how the clinical supervisor will report progress and to whom these
reports will be given
• an understanding of the consequences if there is a recurrence of the suboptimal
practice.
Attending to the above details will assist clinical supervisors and staff in marking the
end of a specific, performance-management supervision task, and the restoration of
a “business as usual” clinical supervision relationship.
Discuss the goals of clinical supervision
It is helpful to talk about the atmosphere clinicians believe they need to develop
their clinical skills. This is likely to entail discussions about the importance of creating
a safe place for clinicians to share information, thoughts and feelings related to
their work. Clinical supervision is different from therapy in that clinical supervision
focuses on the clinicians’ struggles and challenges as they relate to client care. The
process of developing trust and safety in the relationship is introduced in the initial
meeting and is reinforced through the experiences of interacting with the clinical
supervisor in the day-to-day work.
It is also useful to discuss with the clinician the types of approaches available in the
program for professional development and growth. For example, in some programs
two-way mirrors can be used for direct supervision, coaching and feedback. In
others, audio- or videotapes are available. Some programs present opportunities
for learning through co-therapy and review, while others will rely primarily on
case presentation and consultation. This is further discussed in the next section.
Contracts can be general or specific with regards to learning goals, activities and
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Beginning Clinical Supervision
time frames. Contracts can be verbal or written. The following case example
illustrates the process of establishing a verbal contract.
CASE EXAMPLE: DISCUSSING THE GOALS
OF CLINICAL SUPERVISION
Regina, a new clinician who recently graduated from school,
starts a permanent position as an addiction therapist in the residential
program. As part of her orientation, Regina is asked to
meet with the clinical supervisor (an advanced practice clinician)
and manager to discuss roles and expectations, the role of clinical
supervision in this setting, the process of group clinical supervision
and the scheduling of individual clinical supervision. The
clinician is also offered a few definitions of clinical supervision
that are used in this setting.
Because she will report to both the clinical supervisor and manager,
Regina is given some guidelines about areas appropriate for
discussion with the clinical supervisor and other areas to be
discussed with the manager. The APC role focuses on practicerelated
issues through education and support while the manager’s
role is more administrative, as well as being supportive.
In building the relationship with the clinical supervisor, Regina is
asked questions about past clinical supervision as a student as
well as any questions or concerns she has about working with the
clinical supervisor in this setting. From this discussion, the clinical
supervisor learns that Regina experienced her student supervisor
as holding grudges and often felt punished for earlier mistakes in
her placement. This information leads the clinical supervisor
to be sensitive when giving feedback, to acknowledge that the
clinician cannot always make perfect choices and to articulate her
hope that the clinician approach her if she were unsure of her
work in the early days, as a way to obtain help and support.
The clinical supervisor also discusses circumstances that are
somewhat unique to the program. Unlike other settings, there is
opportunity for the clinician to connect with the clinical supervisor
around daily clinical issues. Also, there are some situations such
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Clinical Supervision Handbook
as discharging a client, where a consultation from a representative
from management is required. The clinical supervisor would
share, upon request from the manager, the level of participation
negotiated for clinical supervision, consistent with the initial
discussion of roles and responsibilities.
Finally, the clinician is asked to reflect on her work as a student
and identify some goals she has for this staff position. Regina is
also asked if there are any resources or courses that might
enhance her clinical practice.
WHEN CLINICAL SUPERVISION IS
AT THE REQUEST OF THE MANAGER
When clinicians are told that they are required to attend clinical supervision, a variety
of feelings may arise for both clinician and clinical supervisor. The clinical supervisor
may believe that he or she should have offered supervision earlier or may wonder if
he or she could have provided a more supportive environment so the clinician could
have come to supervision sooner. From the perspective of the clinician, there may be
positive feelings because the clinician has struggled with a clinical situation and now
feels supported by the added attention or help. Alternatively, clinicians can feel very
stressed as they may feel targeted as having done something wrong. Clinicians may
feel that they have been betrayed by sharing their struggle with another member of
the team, and telling the truth about a difficult situation or be embarrassed because
other clinicians told management about unsafe clinical practices. In circumstances
when a clinician is returning to the workplace after disciplinary action, there can be
feelings of anger and embarrassment.
Clinicians may be told to attend clinical supervision because they need to:
• comply with the mandatory regulating body
• acquire skills (required by the program) that can be learned in clinical supervision
• attend clinical supervision as part of a disciplinary action or as part of a return
to work procedure
• integrate evidence-based practice into their work
• focus on client-centred care
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Beginning Clinical Supervision
• manage burnout and workload
• concentrate on a specific deficiency in clinical competency that
has been identified.
Clear contracting is crucial under these circumstances as often the perception of trust,
between team members and management, has weakened and some type of a report is
expected. Some examples of questions to consider for the purpose of clarity are:
• Will the requested need for clinical supervision address the concern entirely or
are there other important components (i.e., training that may or may not be part
of the role of the supervisor)?
• What is the time frame expected for the clinician to accomplish the goal of
clinical supervision?
• What details in the report does the manager expect?
• What will happen if the clinician does not attend or comply?
• What are indicators of compliance?
• What will happen if the clinical supervisor does not write a positive report?
It is helpful to clarify the clinical supervisor’s role to ensure the best outcome of
clinical supervision. Once the role has been determined, the manager, clinician and
clinical supervisor should meet to review the expectations and document what is
being requested.
Similar to the processes described earlier regarding contracting in general and establishing
the working relationship with the clinician, it can be helpful to obtain feedback
about how the clinician feels about the structure of the supervision process.
Additionally, the supervisor can ask the clinician for his or her input, such as: “Since
we are meeting, what would you like to get out of this scheduled time?” Connecting
with the clinician about his or her clinical goals can help the clinician see the value
of clinical supervision, improve his or her professional skills and fulfil the needs of
the program.
CASE EXAMPLE: MANAGER-REQUESTED
CLINICAL SUPERVISION
Jacob, a social worker on a psychiatric inpatient unit, continued
to see the parents of a client after the client was transferred to
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Clinical Supervision Handbook
another clinical team. Jacob did not believe the new social worker
understood the family’s distress or perspective because he
thought he could better identify with their Eastern European background.
When management learned that Jacob was seeing this
family, it was decided that he had overstepped his boundaries
and should have referred the family to the new clinical team. He
was disciplined and asked by his manager to attend clinical
supervision.
Jacob came to clinical supervision not really knowing what to
expect. He recognized that he had overstepped a boundary; however,
he was upset with being disciplined and thought his manager
had treated him unfairly. He also did not want talk to anyone
about the situation because he did not believe that he would be
supported if he sought out clinical supervision. A contract was
developed to reflect the expectation to discuss boundary crossing
and ways that Jacob could approach management for more support
if needed. Also, Jacob was asked if there were any other areas
of skill that he would like to develop in clinical supervision. He
mentioned that given the increased workload in documentation,
he would like some guidance around documentation.
A meeting was set with Jacob, the clinical supervisor and the
manager to discuss the goals of clinical supervision (boundaries,
asking for more support and documentation). It was negotiated
that the individual sessions occur once a week for one month as
this appeared to be adequate time to discuss these topics. After
one month, the clinical supervisor—with Jacob’s input—would
complete a report of Jacob’s progress. If more time were
required, this would need to be renegotiated.
In clinical supervision, Jacob discussed his current clinical cases,
the clinical supervisor brought thoughtful articles and information
for Jacob to consider and documentation was reviewed. After
one month, Jacob felt more confident in his work and better able
to ask for assistance in the future.
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Beginning Clinical Supervision
GIVING FEEDBACK ON PERFORMANCE
The clinical supervisor and clinician should regularly review the clinical supervision
process and recontract when necessary. Later in the handbook, we will discuss ways
the clinical supervisor can request and receive feedback (see p. 92); this section is
meant to provide some ideas about offering feedback to clinicians.
Clinicians will usually have many opportunities to receive feedback. Although
clinicians will learn from a variety of sources, the clinical supervisor has an explicit
responsibility to assist in the clinicians’ development and growth.
The task of providing feedback may feel quite strange especially if the clinical supervisor
has recently been promoted from the role of clinician. A discussion with peer
supervisors about the change of roles at this time can be invaluable. There are many
reasons why a clinical supervisor will have the capacity to provide unique and valuable
feedback. The clinical supervisor:
• can often compare strategies used by a variety of supervisees and offer
opportunities to develop consistency among clinicians
• has more time to look at the bigger picture of the organization’s values and
goals and help to match practice to the organizational context
• is not working directly with the client and therefore has the opportunity to
review issues with more distance and perhaps clarity
• is simply able to provide alternate perspectives that have not been considered.
Feedback should highlight strengths as well as identify opportunities for learning. It
is important to take any opportunity to offer positive feedback. If a clinician shows
strength in some aspect of the work, the clinical supervisor can use this as an opportunity
to highlight the work. By offering this strength-based approach to feedback
early and often, the clinician can place any difficult or change-oriented feedback in
the overall context of a positive work environment that values the clinician’s strengths
and need for continuous learning.
When offering feedback that may be difficult for the clinician to hear, the clinical
supervisor will want to provide an optimal learning environment. The best option is
to offer the feedback in regular individual sessions. If this is not possible, it is wise to
find a time that the clinician can meet without interruption in a confidential space.
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It is helpful to offer the feedback in a way that is specific and concrete. Sometimes
the feedback is about a particular situation and will allow an opportunity for the
clinician to respond and perhaps offer more information. If the issue is not linked
to a specific incident or situation, the clinical supervisor might need to provide
concrete examples to support the feedback. Providing the clinician with an example
illustrates the precise nature of the concern and also gives the clinician a chance
to clarify any misunderstandings. The clinical supervisor may also wish to provide
this feedback in writing.
It is important to offer the feedback in a timely fashion. Although it can seem timeconsuming
to give clinicians feedback that may seem minor, early feedback can
give clinicians the opportunity to absorb the information, respond faster and use
other resources in addition to clinical supervision to assist with making changes
to their practice.
CASE EXAMPLE: FEEDBACK ON PERFORMANCE
Janet is a clinical nurse in an outpatient addiction treatment service.
At her bi-weekly clinical supervision, Janet described working with
a client who was “mandated” by the child protection authority
Children’s Aid Society (cas) and who she felt was “just going
through the motions” to get her child back. The client had stopped
using crack cocaine; however, she reportedly used marijuana
occasionally.
The marijuana use and the fact that the client was not interested
in making any psychological changes concerned Janet and were
the reasons she was asking for clinical supervision. The fact that
the client was intending to end treatment in two more sessions
also caused Janet to worry that she had not done all that she
should to help effect change.
The clinical supervisor first wanted to point out how the sessions
with the client appeared successful in relation to her goals
of treatment, part of which was to see the client stop using
crack. Janet could agree that the previous sessions may have
been helpful but was unsure about whether she had sufficiently
addressed her client’s cannabis use. They discussed the importance
of the therapeutic relationship apart from the client’s
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cannabis use—which Janet felt was quite positive—as well as the
importance of the client’s efforts and strengths outside of the
therapeutic relationship.
The clinical supervisor then explored feelings around the client
“going through the motions” and discussed if this interfered with
Janet’s lack of feelings of success about this client. The clinical
supervisor then asked about whether cas would object to
occasional marijuana use, given that her doctor had prescribed
her marijuana, and concluded this would likely not be a great
concern to cas.
Finally the clinical supervisor gave her some feedback about her
approach with the client. She told Janet that she could use the last
two sessions to tell the client what she really thought about the
marijuana use, or she could work toward cultivating a
relationship with the client so if she ever wanted to address the
marijuana use or her feelings around using crack cocaine, this
would be a safe place for the client to return regardless of whether
she was still involved with cas.
Janet was able to see that her approach to the client had been
focused more on substance use (very common in a substance
use service) and less on maintaining a relationship with the client
to foster further growth and development if the client wished to
seek out further treatment.
LEARNING STYLES
A learning style is “a predominant and preferred approach which characterizes an
individual’s attitude and behaviour in a learning context” (Bogo & Vayda, 1998,
p. 100). Clinicians may not have considered how their learning styles or needs might
differ from those of their colleagues or the clinical supervisor. Learning styles can
vary on a variety of dimensions.
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TYPES OF LEARNING SKILLS
structured
method description
concrete
active
individual
visual
self-directed
unstructured
intuition
abstract
reflective
group learning
auditory
clinical supervisor-directed
There are a variety of models of learning styles available for learners to consider.
Kolb (1984) has developed a highly regarded and utilized model. He presents how
people can learn on two axes: a perceptual continuum from concrete to abstract
and a processing continuum from active to passive. From this work, he presents
four distinct learning styles:
• accommodator
• diverger
• converger
• assimilator.
Accommodator style (feel and do): preference for concrete
experience and active experimentation
Accommodators are “hands on” and rely on intuition rather than logic. They prefer
a practical and experiential approach. Accommodators may prefer to rely on instinct
instead of providing a logical response. This is a useful approach when the situation
requires action and initiative. Accommodators work well on teams to complete tasks.
They set targets and work in the field trying different ways to achieve their objectives.
Learning activities include shadowing, doing the clinical work and talking about it in
clinical supervision or having the clinical supervisor observe the work.
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Diverger style (feel and watch): combination of concrete
experience and reflective observation
Divergers are often able to look at a situation from different perspectives. Such
learners are sensitive, and prefer to watch rather than do, tending to gather information
and use imagination to solve problems. They prefer to work with groups, to
listen with an open mind and to receive personal feedback.
Learning activities include shadowing, role modelling and reviewing teaching tapes.
Converger style (think and do): abstract conceptualization
and active experimentation
Convergers are problem solvers. They prefer to focus on technical tasks, and are less
concerned with relying on others to learn. They are best at finding practical uses for
ideas and theories. They are good researchers and often have technological abilities.
They like to experiment with new ideas, to simulate and to work with practical
applications.
Learning activities include reading various theoretical perspectives, getting feedback
from clinical supervisor reviewing their clinical work, developing treatment plans
and role plays.
Assimilator style (think and watch): combination of abstract
conceptualization and active experimentation
Assimilators are logical and concise. They tend to focus on ideas and concepts. They
look for a clear explanation rather than a practical response. They excel at understanding
wide-ranging, often theoretical information and organizing it in a clear and
logical format. They are less focused on people and more interested in ideas and
abstract concepts. Like the converger, the assimilator likes a scientific approach.
They prefer to read, attend lectures, explore analytical models and have time to think
things through.
Learning activities include reading various theoretical perspectives, viewing learning
tapes, developing treatment plans and watching other clinicians.
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LEARNING STYLES AND CLINICAL SUPERVISION
While most people may see aspects of themselves reflected in each style, each discrete
style can be regarded as a particular type. These types provide ways to help
both clinician and clinical supervisor identify their own preferred learning styles.
Most people will have a mix of styles, but one usually predominates. When clinician
and supervisor have different learning styles, each can expand their repertoire and
adapt to how information is presented and absorbed by the other, producing rich,
new ways of extracting optimal learning from various situations. Supervisors can
assist clinicians to use familiar and new learning styles to try new and challenging
practices, acknowledge discomfort and set goals that overcome barriers.
The supervisor can also share his or her own preferred learning style and then discuss
learning options outside of the clinical supervisor’s preferred learning style. This helps
to stimulate discussions about how the clinician can further enhance his or her clinical
practice and allow for a variety of approaches to be used depending on the clinical
situation. In this way, the clinical supervisor works with the clinician to construct
the best learning environment.
CASE EXAMPLE: LEARNING STYLES
In developing a new psychotherapy group, a clinician had done a
great deal of preparation by reading books on the topic, speaking
to another therapist who leads this type of group and observing a
few sessions of this type of group. However, the clinician still felt
there was more to learn. The clinical supervisor thought there
was little more to offer the clinician to assist in preparation, and
therefore decided to talk about learning styles. The clinician
acknowledged that he was more reflective and enjoyed conceptualizing
the group from descriptions that emerged from the literature.
The clinical supervisor acknowledged that he learned best
with active participation and would be the type of learner who
would start the group and intuitively learn more as he went along.
This allowed both to pause and reflect on what else was needed
for the clinician to feel able to start the group. It was decided that
the clinician was likely ready to start the group in two weeks and
both would assess progress as the group went forward.
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As this example illustrates, the clinician and clinical supervisor
were able to address the learning needs of the clinician by first
discussing their own unique learning styles. These discussions
can further assist in developing new ways to plan, conduct and
evaluate the learning. Often this will come about as part of a discussion
when some type of mismatch is occurring. This discussion
can lead to a positive and productive discussion of clinical
practice.
Ongoing Clinical Supervision
METHODS OF CLINICAL SUPERVISION
There are a variety of methods used to provide clinical supervision. Some include
direct observation of the clinician and/or supervisor at work with clients and others
rely on review of clinicians’ work by examining audio, video or written records or by
verbal case presentations. This section discusses four of these methods:
• demonstration / reflecting mirrors
• co-therapy
• role-playing
• reviewing audio and / or videotapes.
These methods address the various learning styles described by Kolb: accommodator,
diverger, converger and assimilator.
Demonstration / reflecting mirrors
Demonstration
Typically, the clinical supervisor and clinician meet in advance and discuss a particular
struggle that the clinician is having or identify a particular set of skills that the
clinician needs to learn. Then the clinical supervisor meets with the clinician and his
or her client and takes the lead in the interview with the client. The clinical supervisor
debriefs with the clinician afterward, asking the clinician what he or she noticed and
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how the clinical supervisor’s responses were similar and different to those of the
clinician. The clinician is present during the interview between the client and the
clinical supervisor and the debriefing is an opportunity for the clinician to compare
what the clinical supervisor did with what the clinician would have done if he or
she were conducting the interview.
Reflecting Mirrors
In the reflecting mirrors technique, the clinical supervisor is in a room with the
client. The clinician sits outside of the room, looking through a reflecting mirror.
The process is the same in terms of how the interview is set up—purpose, goals,
process, debriefing. The supervisor and clinician roles can be reversed, with the
clinical supervisor observing the clinician interview the client.
CASE EXAMPLE: DEMONSTRATION
Both the Keeping Safe and Enhancing Women’s Well Being
groups are co-facilitated with a member of staff or a student as a
way of modelling how to run the group. The clinical supervisor
shows them how to:
• help the group establish norms
• review the content of the handouts in a way that respects the
needs that the clients bring forward in the sessions
• manage conflict within the sessions
• ensure there is a balanced opportunity for clients who tend to be
silent and for those who are more outspoken to share the floor
• elicit opportunities for clients to hear the commonality of experience
and learn that they have something to offer one another
• demonstrate respect for the clinician/student co-facilitator by
verbally underlining meaningful interventions that she or he
makes and returning to them if they get lost in the session.
CASE EXAMPLE: ONE-WAY MIRRORS
For the Enhancing Women’s Well Being Group, the clinical supervisor
facilitates the sessions with a graduate student in a room
that has a one-way mirror. While this method is used for student
learning, it can also be used for staff development. Other students
and staff are invited to observe. They are given a sheet of
paper with specific questions to reflect on as they watch the
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group. The clinical supervisor uses these questions to shape the
learning experience for all supervisees. The questions are:
1. What is different and similar about this group and other groups
you have observed or participated in?
2. How is gender playing itself out in this group? What themes do
you notice?
3. How are diversity issues experienced in this group (i.e., class,
culture, sexuality)?
4. What questions do you have about the choices that the co-facilitators
made in terms of facilitation during this session?
General comments and debriefing
A range of questions can be used depending on what the supervisor intends observers
to learn from the observation experience. For example, MacKenzie (1990) developed
a Group Climate Questionnaire that asks observers (and group members and facilitators)
to rate the group as a whole along various dimensions that break into three
subscales: engaged (a positive working environment), conflict (a negative atmosphere
with anger and distrust) and avoiding (of personal responsibility for group work).
Using a tool like this increases observers’ awareness of the interaction between members
and between members and facilitators. The tool reinforces the differences between
working with clients individually and within a group, highlighting areas to explore
further in future sessions when gaps are noticed.
After the group, the co-facilitators debrief with the observers, discussing their responses
to the questions as well as processing their observations of group member interactions
and what they observed the co-facilitators do. This provides an excellent learning
opportunity for all involved since there are often a variety of strategies that can be
used at any given time.
Co-therapy
Co-therapy is the joint facilitation of a client group by two clinicians—in this case,
the clinician and the clinical supervisor. This allows the clinician to observe the
strategies used by his or her clinical supervisor, and it enables the clinical supervisor
to observe the clinician’s interventions and to provide immediate feedback.
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CASE EXAMPLE: CO-THERAPY
The clinical supervisor meets with the staff member before he or
she begins co-facilitating in order to provide some background /
history of the group, its goals, co-facilitators’ roles, what the clinician
can expect to occur, and to explore what the clinician feels comfortable
doing. The clinical supervisor continually evaluates the
clinician’s involvement and interventions over time and monitors
the clinician’s desire to take more risks within the group.
Prior to each session, the clinical supervisor and staff member
(co-facilitators) meet briefly to discuss the plan for that day. For
the Enhancing Women’s Well Being Group, which is a 14-session,
closed outpatient group, there is greater opportunity for continuity
since the same people facilitate for the whole cycle. The cofacilitators
can review previous sessions and decide what needs
to be followed up on and what roles they might each take for the
particular meeting.
After the session, the clinical supervisor takes some time to
debrief. During this time, the co-facilitators reflect on what
occurred with respect to the clients—themes, participation level,
critical issues—and what they noticed each other do and the
response from clients. This provides them with the opportunity to
notice how their skills are developing and the impact their strategies
are having on the group. The clinical supervisor shares what
she was thinking during the group that influenced what she said
or did not say. After the clinical supervisor has modelled this
process, the staff member does the same, which expands the
opportunity to discuss what he or she did and did not do and the
reasons underlying interventions. The co-facilitators discuss what
their follow-up will be in the next session and the cycle continues.
The clinical supervisor invites her co-facilitator to risk trying a
strategy that the clinician had thought about, but had not done.
Within the Keeping Safe Group, staff members learn that even
though it theoretically makes sense for the program’s clients to
have safety plans, the process goes beyond ensuring that clients
have completed these plans. Staff members need to be open to
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Ongoing Clinical Supervision
reflecting on the barriers that clients experience, speaking about
what prevents them from being able to follow through on using
their plans, and helping clients process their resistance as
opposed to getting into a power struggle with them.
Role playing
After the clinician describes a challenge he or she is encountering with a client, the
clinical supervisor can suggest a role play where the clinician and clinical supervisor
act out the situation where the clinician had trouble. For example, if the clinician
plays the role of the client, the clinical supervisor can show the clinician other ways
of responding to what the client is saying. The roles can be reversed, with the supervisor
taking on the client role. This variation requires that the supervisor has enough
information about the client’s responses to be able to respond meaningfully. The
supervisor can see how the clinician responded to the situation in question and then
give feedback.
Reviewing taped sessions
The clinician is asked to either audio- or videotape the session or sessions with a
client. The clinician must ensure that the client understands that this is being done
to help the clinician provide optimal care. After this has been explained, the clinician
must obtain written consent from the client. The clinician reviews the tape and
marks the segment that he or she would like to discuss with his or her supervisor.
The clinician plays this segment during the session and the clinician and clinical
supervisor discuss their observations. The clinician may first be asked to talk about
what he or she was thinking and feeling at the time and how these thoughts and
feelings contributed to what he or she did or did not say.
CULTURAL COMPETENCE AND DIVERSITY
Influence of privilege and oppression
in the therapeutic relationship
Skilled clinicians possess knowledge and understanding about how oppression, racism,
discrimination and stereotyping affect them both personally as well as in their work.
They are knowledgeable about how sociopolitical influences impinge on the lives of
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people who are marginalized because of race, culture, gender, sexuality, age, language,
religion and abilities. Without this awareness, clinicians can respond to their clients
with a range of feelings such as anger, defensiveness, sadness and powerlessness, and
miss opportunities to explore how these life experiences have contributed to the
client’s mental health and addictions. The Wheel of Intersecting Axes of Privilege,
Domination and Oppression (see Figure 1, p. 43) is a tool that can be used to help
clinicians raise their awareness in this area as they plot themselves along the various
axes and consider where their clients are located as well. This helps to identify where
there might be tensions in the clinician-client relationship due to meanings that
either person may attribute to specific incidents within the relationship based on life
experience. This tool also facilitates the exploration of contextual factors that are
important to consider as the clinician assists the client in his or her recovery. For
example, a client is not open about her sexual identity as a lesbian. Keeping this
hidden influences her relationships with others resulting in shame, guilt, depression
and anxiety. She drinks to cope. The clinician assumes the client is heterosexual
and thus misses a key issue that has contributed to the client’s mental health.
Using the tool
Introduce the tool to clinicians by explaining the rationale for its use, as described
above. Then ask the clinicians to take some time and put an “X” on each axis at the
point that represents where they see themselves. If this exercise is done in group clinical
supervision, tell the clinicians that they are not required to share the details with
the group. After they have completed the exercise, ask them what they noticed—did
anything in particular jump out for them? Many people are surprised at the number
of axes and how they experience greater privilege in some areas as opposed to others.
Next, ask the clinicians to think about the clients they currently see and to place
them on all of the axes based on what they know about them. Then ask how they
think their experiences and those of their clients might influence their relationship
with one another. For example, the clinician is a Caucasian, well-educated woman,
middle class, married, with two children. Her client is a single, black woman, making
enough money to pay her bills, raising three young children on her own. She did not
complete high school. She has been involved in the sex trade as her main source of
income to support herself and her children. She uses alcohol and marijuana to cope
with her feelings, and the experience of having been sexually abused in childhood
by her father. Based on the clinician’s experience and biases, she or he may not raise
questions about how racism and childhood sexual abuse may have contributed to
dropping out of school, having limited employment opportunities due to discrimination
and an overall poor sense of self.
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FIGURE 1: THE WHEEL OF INTERSECTING AXES OF PRIVILEGE,
DOMINATION AND OPPRESSION
Source: From A., Diller, B. Houston, B., Morgan, K.P. and Ayim, M. (1996).The Gender Question in Education: Theory,
Pedagogy, and Politics. Boulder, CO: Westview Press. Reprinted with permission.
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Questions for reflection
In addition to using the diagram, clinicians are asked to consider the following
“Questions for Reflection” to further explore what influences their perceptions of the
client in addition to experiences of privilege and oppression. Through this exercise,
the clinical supervisor helps the clinician to break through stereotypes; acknowledge
his or her beliefs and values; and understand how stereotypes, beliefs and values can
be barriers to understanding the client’s experience. The exercise may raise new
issues for discussion with the client (e.g., asking about experiences of discrimination,
and what it is like for them having a therapist who is from a different culture, race).
These questions were developed by Donna Akman, PhD, CPsych, and Cheryl
Rolin-Gilman, rn, mn, cpmhn(c), Women’s Program, Centre for Addiction
and Mental Health.
A Thoughts/feelings about client/session:
• What am I puzzled by with this client/situation?
• What occurred in the interaction with this client?
• What were my thoughts and feelings?
B
Personal/social location:
• What is my personal/social location with respect to this client,—i.e., along continuum
of privilege to oppression—(race, gender, language, sexuality, race, ability, education,
age, fertility, European in origin vs. non-European, Aboriginal, attractiveness,
colour, etc.)?
C Observations/reflections about session:
• What did I learn from observing/reflecting on my experience? What are the
essential aspects that I am aware of?
• What are alternative methods of action that I can take with my understanding?
D From the questions below, choose one that you would like to discuss:
• What factors influenced my response in this situation?
• What was I trying to achieve?
• How were others feeling? How did I know this?
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• Does this situation connect with previous experiences I have had?
• How do I feel about this experience?
• What were my hopes for the outcome of this incident?
• How were my hopes related to my own expectations?
• What are the sources of my knowledge in my life and work?
• What are the sources for my ideas and values?
• To what extent were social norms or expectations (including organizational)
operating in this incident?
Adapted from: Johns, C. (2000). Becoming a Reflective Practitioner: A Reflective and Holistic Approach to Clinical
Nursing Practice Development and Clinical Supervision. Oxford, England: Blackwell Science.
Tate, S. (2004). Using critical reflection as a teaching tool. In S. Tate & M. Sills (Eds.), The development of critical
reflection in the health professions. Occasional paper (4). Learning and Teaching Support Network (LTSN) Centre
for Health Sciences and Practice, (pp. 8–17).
GROUP SUPERVISION
Although the literature tends to focus on individual clinical supervision, given time
and budget constraints, clinicians will probably be more exposed to group supervision.
The following is adapted from a series of studies on group supervision conducted
by Bogo, Globerman and Sussman (2004a).
In group supervision, a group of clinicians meet on a regular basis with one supervisor.
Group supervision allows clinicians to present examples of their practice and, through
discussion, learn from exposure to a wide range of ideas and perspectives offered by their
supervisor and peers. Through peer interaction, clinicians can develop a more accurate
self-appraisal of their ability and learn about group process and group dynamics.
Groups can function in different ways. Examples include rotating case presentations
or focusing on particular topics and their relationship to the therapeutic relationship
(e.g., working with clients with a trauma history, stage-oriented trauma treatment).
Novice clinicians have the opportunity to learn from experts. Experts develop by
demonstrating their ability to self-reflect. They do this by bringing their experiences
of their clients to the group, and by sharing their thought processes as they discuss
the questions they have asked themselves in order to better understand the choices
they made in response to their client’s behaviour. They talk about the connection
they make between theory and similar situations they have encountered with other
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Clinical Supervision Handbook
clients, illustrating where they have been able to generalize an approach and where
they have had to make modifications.
Purposes of group supervision
Group supervision provides opportunities for clinicians to learn skills in peer supervision
and to experience support from colleagues who may be struggling with similar
feelings around caring for a challenging client. Group supervision can also contribute
to team cohesiveness and provide a rich experience for exploring several different
perspectives. Group supervision may be more feasible than individual clinical supervision,
particularly on a busy inpatient unit where taking time away to meet oneto-one
may not always be practical. It may also be a desirable method of supervision
with reduced resources.
Successful group supervision
Group supervision is most successful when the supervisor is available and supportive,
and regular scheduled sessions are offered that are flexible in duration and protected
from interruptions. Supervisors can show support by demonstrating respect for
the supervisees, by not minimizing their opinions, and by allowing them to make
mistakes. Successful group supervision is highly dependent on the supervisor’s ability
to assist group members to process group dynamics, especially when they interfere
with sharing practice and learning issues.
Leadership style
Clinical supervisors need to provide staff with an orientation to group supervision.
Staff members must feel safe (i.e., not feel embarrassed, shamed or sense that others
are competing with them to be the “best clinician”) and understand what is expected
of them. They should also be asked what they expect from the group and the supervisor.
The clinical supervisor should ensure that both content and process issues are
addressed. Clinical supervisors model expected behaviour of a group member and
provide feedback in a way that focuses on the clinician’s strengths rather than his or her
mistakes. They intervene when group members’ behaviours do not support the norms
of risk-taking and providing constructive feedback. For example, in the case of a
clinician who does not discuss difficulties that she or he has working with clients,
tending instead to focus on questioning others about their practice, an intervention
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by the clinical supervisor might be to ask the clinician if he or she ever experiences
what other group members are discussing (e.g., similar feelings in response to client
behaviours) and how the clinician dealt with these feelings when they arose. Clinical
supervisors provide equal opportunity for each clinician to participate, rather than
favouring one clinician over others.
Benefits of group supervision
Group supervision:
• allows for learning from other clinicians’ interactions with clients; from the
diverse backgrounds and experiences of both clinicians and clients; and from
different perspectives on issues
• provides opportunities for reflection and discussion with others—hearing how
others reflect on their work, including the kinds of questions they ask
• examines the relationship between theory and practice
• helps clinicians learn about group dynamics
• allows clinicians to practice new behaviours
• demonstrates the universality of concerns, such as, “I am not the only one who
thinks they do not know what they are doing” or “I am not the only one who is
feeling hopeless about this client situation”
• helps clinicians develop more accurate self-appraisals.
Obstacles to productive group supervision
Learning is compromised when some or all of the following occur.
Content issues
• There is too much focus on administrative issues such as scheduling
and procedures.
• Not enough time is spent reviewing clinical issues.
• Too much time is spent sharing information rather than on reflection and dialogue.
Process issues
• Group supervision turns into individual supervision with an audience (i.e., clinicians
place themselves in a vulnerable position by disclosing their struggles while the
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rest of the team says nothing and the supervisor only focuses on the presenting
clinician).
• The supervisor does not process feedback from others (i.e., no one ties feedback
together or links to others’ experiences).
• Clinicians feel overly criticized.
• Clinicians feel others are not taking risks.
• A lack of open communication impedes group cohesion.
• The clinical supervisor shares conflicts with staff, personal issues or his or her
own frustrations about clients in a non-professional manner.
• Conflicts occur with team members who are attending the supervision and others
who are outside of the group. (It is helpful to have strategies to address this within
the group.)
Importance of trust and safety in group supervision
The development of trust and safety may be impeded when a member of the group
takes on the role of “consultant” (i.e., the person who is never listening, always “one
upping” other team members, or giving an answer or suggesting a “better” approach).
For example, group members who do not take risks, who only present the cases
they are not having difficulty with and do not reflect on their own practice in group
supervision tend not to bond with the group. Trust and safety in the group may be
compromised when the members vary significantly in their approaches to practice,
and/or when members come from a variety of disciplines with varied levels of
experience.
Open vs. closed group
Providing group supervision on an inpatient unit with an interdisciplinary team
requires some flexibility due to nurses’ schedules. Having a closed group requires
nurses to come in on days off. Open groups accommodate a variety of schedules.
However, they present other challenges.
In an open group, participants may be reluctant to self-disclose. How much a clinician
chooses to self-disclose often depends on the cohesion of the group as a whole and the
mix of staff attending the group that day. Closed groups can achieve a greater sense of
cohesiveness and safety, making it easier for staff members to expose their vulnerability.
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Other disadvantages of open groups include an absence of focus and the need to
repeat content. In a closed group, clients can be discussed over time, with more
opportunities for clinicians to report on results of following through on recommendations
and the insights that emerge during group clinical supervision. When the
group is open, this kind of continuity is more difficult. The clinical supervisor needs
to deal with the needs of the group generated by the most emergent needs of clients
currently on the unit.
Five tips to successful open-ended groups
1. Review group norms for every group meeting and have a handout
available that outlines the norms.
2. Offer group members an opportunity to provide a case outline
for any ongoing case.
3. Obtain feedback from all staff on a regular basis both from
those who attend and those who do not to assess the effectiveness
of the group.
4. Ensure that there is a focus from group to group relevant to all
participants and be prepared with potential topics for discussion
(e.g., ethical dilemmas), should the group have difficulty
identifying a focus.
5. Avoid repetition of content because group members who
attend regularly may get bored and frustrated.
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Strategies to promote group cohesion
Structure
• Teach group skills and how they relate to group rationale and goals for group
supervision.
• Clarify purposes of the group (informational, educational, administrative).
• Explain how clients will be discussed, group norms, structure, how feedback will
be given and received, how time is shared, how conflict and competition in the
group will be handled.
Group process
• Encourage open communication about current and immediate issues among
group members, such as group tensions.
• Intervene to ensure that group norms are respected.
• Provide leadership by modelling and identifying facilitative group member
behaviours, such as risk taking, and providing constructive feedback.
• Facilitate focused discussion and feedback.
• Provide supportive and helpful feedback.
• Ensure that feedback about practice is balanced and focused and propose
possible next steps.
• Encourage team members to respond to each other’s concerns in a positive
manner.
• Ask direct questions regarding clinician’s experiences if soliciting ongoing group
feedback is a challenge, such as “sometimes clinicians can feel overly criticized
in group supervision. Are any of you having that experience in this group?”
This targeted feedback may encourage more group level disclosure because it
normalizes clinicians’ concerns.
• Validate different perspectives and approaches and stages of learning.
• Rework formative stages of group process.
• Discuss what is and is not working in the group process.
• Provide time for critical reflection on practice and integrate theory and practice
in each session.
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Yalom’s therapeutic factors and group supervision
• Yalom’s therapeutic factors are listed below and described in relation to the experience
of being a member of a supervision group:
• Instillation of hope: Within the context of group supervision, clinicians get a
sense that there is light at the end of the tunnel when working with challenging
clients. Hearing the experiences of others can highlight progress that the presenting
clinician might have lost sight of because he or she has lost some objectivity.
• Universality: A sense that clinicians are not alone in the work they are doing and
how they are feeling. Feeling validated from other clinicians who discuss similar
experiences with clients.
• Imparting of information: Providing information to others about the client, how
to work with them or the process of self-reflection.
• Altruism: Having the opportunity to help other staff.
• The corrective recapitulation of the primary family group: Traumatic re-enactments
play out in the team based on the clients projected experiences, power differentials
within the team and how these are processed, parallel process and how conflicts
are managed within the team.
• Development of socializing techniques: Learning how to communicate with one
another within the team using interpersonal feedback and constructive feedback
without judgment.
• Imitative behaviour: Learning how other team members work with clients and
each other by observing what they say and do in supervision.
• Catharsis: An opportunity to vent and label feelings.
• Existential factors: Issues that come from the person’s confrontation with the
“ultimate concerns of existence”: death, freedom, isolation and meaninglessness.
In working with clients, a significant existential issue that clinicians encounter
over and over again is human suffering. Having an opportunity to process these
issues is helpful to clinicians who may otherwise feel overwhelmed.
• Cohesiveness: The sense of belonging and value within the team.
• Interpersonal learning: How the team interacts with one another in the here
and now while discussing a client can be a reflection of the client’s relationships
in the world outside (e.g., staff that takes on the negative aspects of the clients,
those who are the vessels of the positive) (Yalom, 1995).
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An example of group clinical supervision
We find that the clinicians’ experience is most helpful and safe when it is structured
in such a way that the expectations of all participants and what is expected of the
participants are clear. This allows them to come to the sessions prepared, understanding
their roles in the context of the person requesting assistance and giving
constructive feedback to others.
CASE EXAMPLE: GROUP CLINICIAN SUPERVISION
The clinician begins by presenting a clinical dilemma in the form
of a question so the group has a frame of reference before hearing
about the client. An example of this would be, “I would like
your help with the client I am going to present. I am feeling stuck
and would welcome your ideas about how to help the client consider
some other alternatives.” Another example might be, “This
client is feeling overwhelmed with many stressors in her life. She
isn’t working. Her kids are a handful for her. She does not feel
safe where she is living. She continues to have flashbacks and
nightmares. When I listen to her, I don’t know where to start.
I feel overwhelmed myself. I would welcome your ideas.” The purpose
of introducing this question is to keep the feedback focused,
diminishing the possibility of a “free-for-all.” Other clinicians
might ask several questions that do not address the needs of
the clinician and assume the clinician has not already covered or
considered what is being asked. After the question / dilemma
is put forward, the clinician presents some background on the
client (e.g., major concerns, history of her or his work with
the client, attempted solutions—material that directly relates to
the question).
As the clinician receives feedback from the group, he or she takes
notes and then shares what most stands out and what specifically
was gleaned from the consultation. The clinician then discusses
what she or he would like to try and how it might be helpful. The
clinician will then make a note of this recommendation in the
progress note or on the Interdisciplinary Plan of Client Care.
In a round table format, each person is invited to ask one question
of the clinician once he or she is finished providing the overview.
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Individuals may pass if they do not have a question. Specific
questions are intended to help the other consultants develop an
understanding of the client. The clinician provides brief answers
to the questions and makes a special note of questions he or she
cannot answer, as these may be keys to future possible solutions
to consider. Examples of questions could be, “What happens
when you suggest the strategies that you have with your client?”
“Do you know if she has had similar experiences within other relationships?”
“Do you know about the community resource that
can help her with…?” If individuals wish to do a second or third
round of questioning (depending on the size of the group), they
may do so, again with options to pass. The discussion is opened
up to everyone, and ideas offered in a spirit of curiosity. This is an
important point to emphasize so that clinicians don’t feel as
if their colleagues are attacking them or that the questions are
coming from a place of judgment and competition rather than a
desire to be helpful.
INDIVIDUAL CLINICAL SUPERVISION
Individual clinical supervision is the most widely used model of clinical supervision
in social work practice (Kadushin & Harkness, 2002), and has been described by
nurses as a valuable process providing the time to reflect on and learn from their
practice (Teasdale et al., 2001; White et al., 1998). Nursing best practice guidelines
for establishing therapeutic relationships recommend the provision of clinical
supervision to support the establishment of therapeutic relationships between
nurses and clients (rnao, 2002). Clinical supervision is an opportunity to help and
support clinicians to reflect on clinical dilemmas, challenges and successes; and to
explore how they responded to, solved or achieved them (Cutcliffe & Lowe, 2005).
It is a forum for considering the personal, interpersonal and practical aspects of
care to develop and maintain clinicians who are skilled and self-reflective (Cutcliffe
& Proctor, 1998).
In individual clinical supervision, concepts crucial to the development of therapeutic
relationships with clients, such as trust, respect, empathy, empowerment and a nonjudgmental
approach are understood by developing a trusting, supportive relationship
with a clinical supervisor. The supervisory process is like a journey as clinical supervisor
and clinician explore clinical material together, with a view to arriving at a deeper,
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more meaningful understanding of the client. In this way, the supervisor-clinician
relationship parallels the clinician-client relationship.
Beginning individual clinical supervision
The first task of the clinical supervisor is to create a safe space in which the clinician
can re-experience clinical difficulties and the feelings associated with them. Creating a
safe space and a supervisory alliance with the clinician involves developing a trusting
relationship and providing education regarding clinical supervision: what it is and
how it works (Gallop, 2004). This is particularly important because clinicians will
bring their own perceptions of clinical supervision to the supervisory relationship.
Exploring previous experiences with clinical supervision and the feelings associated
with these will provide an opportunity to correct any misconceptions that the clinician
has about the supervisory process. Even if the clinician has not had clinical supervision
before, it will be important to explore preconceived notions about it. The word
supervision itself may conjure up negative feelings, particularly from nursing staff
where historically, it was associated with management and surveillance. On the other
hand, social workers view clinical supervision as a crucial component of their practice.
Education regarding supervision should also establish clear boundaries by not only
addressing what clinical supervision is, but also addressing what it is not; for example,
clinical supervision is not personal therapy. The focus is on the clinician-client
relationship. Having said that, there may be times when personal issues are having
an impact on the clinician-client relationship and this needs to be acknowledged.
A safe space is further constructed by scheduling regular time to meet with the clinician
in a private place, such as the supervisor or clinician’s office. Scheduling a minimum
of 45 minutes to one hour every four weeks for individual clinical supervision is
recommended in the nursing literature (Butterworth et al., 1997; White et al., 1998)
while social work supervision is usually provided weekly or every second week.
Winstanley and White (2003) note that clinicians in monthly or bimonthly sessions
scored higher on the Manchester Clinical Supervision Scale (Winstanley, 2000), a scale
that measures the effectiveness of clinical supervision. Supervision time is protected,
uninterrupted time that both clinical supervisor and clinician respect. The clinical
supervisor demonstrates his or her availability, consistency, respect and reliability
by being present and punctual, which not only serves to establish a trusting, safe
relationship with the clinician but also models qualities that clinicians ideally transfer
to their clinical practice to build therapeutic relationships with their clients. Some
clinicians may be reluctant to engage in scheduled supervisory sessions or may feel
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they cannot take time away from a busy inpatient unit. These clinicians may prefer
more informal support at least as a starting point to building trust and engaging in
more formal clinical supervision (see Spontaneous Supervision, p. 66). Additionally,
engaging inpatient nursing staff in particular in individual clinical supervision can
be challenging due to unit constraints (see Nursing and Clinical Supervision, p. 75).
Confidentiality is critical to the development of a safe and trustworthy environment.
The clinical supervisor explains that discussions in the sessions are confidential. The
only time this confidentiality is broken is if the clinician has been involved in unsafe
or unethical behaviour with a client. The supervisor must confront such behaviour.
Ideally, the supervisor helps the clinician identify the problem and initiate corrective
action. The supervisor monitors the process (Gilmore, 2001). If supervision has been
mandated, the supervisor is obligated to share information with the manager. (See
When Clinical Supervision is at the Request of the Manager, p. 28). A strong confidential
ethic contributes to a safe environment. Without the establishment of a safe
environment, the clinical supervisor and clinician will be less likely to explore the
more risky aspects of unprofessional practice (Epling & Cassedy, 2001).
A discussion of goals is important to the development of a focus for clinical supervision
sessions (see Beginning of the Relationship and Contracting, p. 23). Clinicians
may come with very specific goals, such as addressing difficulties experienced while
caring for a particular client, a client population or diagnosis, or they may require
assistance in exploring and developing their goals within a framework of clinical
supervision. Frameworks or models of supervision within both nursing (Proctor,
1991) and social work (Kadushin, 1976) frequently include the components of
support, education/learning and administration, and supervision is described as a
reflective process (see Appendix 1, a review of the literature, pp 103). It is important
to note, as Fowler and Chevannes (1998) suggest, that some clinicians may not be
ready to or able to cope with intense examination of themselves and their work. If the
clinician is inexperienced clinically, then a focus on reflection may not be appropriate,
at least not initially. A more directive approach such as a preceptorship may better
meet the clinician’s goals, with clinical supervision being available when the clinician
is more experienced.
The opportunity to off-load in the context of a supportive relationship builds trust
and a foundation for later exploring clinical material in more depth. Caring for
clients living with mental illness and/or addictions is hard work. Listening to clients’
stories and bearing witness to their pain and suffering can take a toll on clinicians
and contribute to burnout and low morale. Novice clinicians may be particularly
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vulnerable to feeling alone and overwhelmed. An affirming and empathic supervisory
experience can enhance morale and increase self-confidence. It provides a starting
point, and a strong foundation in which the clinician feels safe, supported and gradually
is able to take more risks within the relationship. Similarly, this opportunity to
off-load and receive support is critical in the development of a therapeutic alliance
with clients. In this way, the supervisor-clinician relationship mirrors the clinicianclient
relationship as an experience of feeling comforted and understood.
The working phase of individual clinical supervision
Once a trusting, safe foundation is established, the clinical supervisor and clinician
begin the process of exploring and understanding thoughts and feelings, such as
those experienced by the clinician toward the client, and the client toward the clinician.
Developing a deeper understanding enables the clinician to respond in a less
emotionally reactive and more conscious, thoughtful manner to the client (Gallop,
2004). Ideally, it is the clinician or the supervisor-clinician dyad that arrives at this
deeper understanding of a particular client situation. If this doesn’t happen, the clinical
supervisor may need to take a more directive approach at least in the earlier
stages of supervision. The process of journeying together is modelled by the clinical
supervisor, as illustrated in the vignette below, and is empowering to the clinician. In
the clinician-client relationship the therapist models a similar process of journeying
with the client, as issues are explored and better understood.
Part of the journey includes the development of self-awareness in the clinician and a
recognition that his or her own experience is influenced by multiple factors such as
race, culture, health, socio-economic conditions, gender, education, early childhood
experiences, current relationships, beliefs and so on. With the development of this
self-knowledge the clinician is better able to distinguish between her own experience
and values, and those of her client. “In this way, she is able to appreciate the unique
perspective of the client, is able to avoid burdening the client with her issues, and
can prevent imposing her own beliefs and preferred solutions upon the client”
(rnao, 2002).
The following example illustrates some of the concepts discussed so far.
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CASE EXAMPLE: A NURSE IN INDIVIDUAL
CLINICAL SUPERVISION
A nurse on an inpatient unit met with her supervisor to discuss a
client with whom she was having difficulty engaging. This client
had a chronic mental illness and also suffered from diabetes. The
nurse described her interactions with the client and talked about
how she was focusing on the client’s diabetes, which was not well
controlled, and her mental illness. She herself felt as though she
was “nagging” the client “all the time” about the importance of
following a diet to better control her diabetes. The client became
withdrawn and uncommunicative in her interactions with the
nurse. The nurse said she had reached an impasse with this client.
The clinical supervisor explored the nurse’s feelings, as well as
how the client may have been feeling. The nurse felt like a
“nagging parent,” constantly pointing out to the client what she
ought to be doing. She cared for the client and was fearful that the
client’s health would deteriorate further, and she would never get
better if she did not adhere to her dietary and treatment regime.
She also felt a sense of urgency and responsibility, given her timelimited
involvement with the client as an inpatient nurse. If the
client didn’t get better, she wasn’t doing a good job. The client,
she thought, may have felt powerless, frustrated and tired of
“being a patient.” The nurse and the clinical supervisor began to
wonder if her focus on the client’s illness was interfering with her
seeing the client as a whole person and with getting to know her,
beyond her illness. Perhaps that is why the client had withdrawn.
Together they explored an empathic perspective and tried to see
and feel the world as her client was seeing and feeling it. They
wondered: what was it like for her to be ill and in hospital? How
did it feel for her to have so much of her life revolve around “being
a patient”? How did it feel for her to be dependent on others for help
indefinitely? By trying to experience the client’s world from her
perspective, they came up with an intervention aimed at helping
the nurse reconnect with her client. This involved taking the client
off the unit, perhaps for a walk or to the coffee shop (the client
would decide on the activity) in a “less illness” focused context
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and trying to engage her around non-illness related topics—getting
to know her as a person, her hopes, her dreams, her interests,
her past and so on.
For the next four weeks, the nurse did this. When the clinical
supervisor met with the nurse again she described the process
and outcome. The client chose the coffee shop and they made a
point of going there to “chat” at least once a week. The nurse
refrained from discussing the client’s illness during these outings,
and instead explored topics of interest to her client—they talked
about what her life was like before she became ill, how she liked
to dress and wear her hair; and her dream to work as a hair stylist.
These outings to the coffee shop became important to the client
and she looked forward to them. The nurse noticed that over the
course of the next four weeks, her client became much less defensive
with her on the unit, and more relaxed. She started to pay
more attention to her dress and her appearance. Eventually she
was receptive to the nurse addressing her illness issues again.
When the client was discharged from the hospital she gave the
nurse a coffee mug. The clinical supervisor and nurse discussed the
significance of this, an affirmation that these trips to the
coffee shop had been meaningful to the client and had contributed
significantly to them working together therapeutically to
achieve a positive outcome.
This clinical situation highlighted for the nurse the limits of her
role and resulted in her understanding more clearly that she
could not “control” the client. By taking a holistic approach to the
client, getting to know her beyond the illness, she communicated
respect for her client as a person, understanding and a hopefulness
that facilitated the therapeutic relationship and contributed
to the client’s recovery. This example demonstrates how concepts
such as holistic care, empathy and recovery are woven into the
supervisory process. For the nurse, these concepts are brought to
life and more deeply understood as they are experienced in the
context of a real therapeutic relationship.
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Another example highlights the concept of empathy and its role in developing therapeutic
relationships.
CASE EXAMPLE: A CLINICIAN IN
INDIVIDUAL CLINICAL SUPERVISION
A clinician was providing care to an outpatient, a young woman
who was recovering from a first episode of psychosis. All
attempts to engage her in a dialogue about the illness and discuss
the need for ongoing medication had failed. The client
would “shut down” and repeat very defensively that she was fine
and she didn’t need to talk about this.
When the clinician met with her clinical supervisor, she shared
her frustrations about the client not being receptive to her health
teaching and education about her illness. The clinical supervisor
acknowledged her frustration and explored her feelings, further
revealing the clinician’s concerns about this client becoming ill
again if she did not develop insight into her illness. Together, they
stepped back and tried to look at the situation from the client’s
perspective. The clinical supervisor asked the clinician to tell her
more about this young client. The clinician described a young
woman who had just experienced a first episode of psychosis.
She had been functioning well prior to the illness, attending
university and had lots of friends. She had to take time off university
to recover from her illness, and felt cut off from her friends. The
clinician and clinical supervisor talked about how the client now
had to come to terms with having suffered a highly stigmatizing
illness that had significantly interrupted her life. They talked
about the implications of her illness, which included an uncertain
future. Together they arrived at a more meaningful understanding
of what might be going on inside this young woman.
The next time the clinician met with her client the following interaction
unfolded:
Clinician: “I’ve been thinking about our meetings and have realized
that I’ve been talking a lot about the importance of medication in
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preventing further illness episodes. And I’ve noticed that isn’t of
much interest to you right now.”
Client: nodded her head in agreement
Clinician: “I’m wondering how you’re feeling about this illness
right now (pause) and I’m thinking that it must really suck. It’s
really interrupted your plans.”
Client: Tears start to well up in her eyes as she says angrily, “I hate
it. I don’t want to take medication. I don’t want to be sick. Why
can’t things just be the way they were before? It’s just not fair!”
Clinician: “Yes. You’re right. It’s not fair. It’s awful when something
disrupts your life like this, especially an illness. I can understand
why you feel so angry and sad and just want it all to go away.
Client: nods and begins to weep.
This vignette illustrates how an empathic approach allowed the clinician to attend to
the subjective experience of the client and validate that her understanding was an
accurate reflection of the client’s experience. She gained entrance to the client’s inner
world and was able to better understand the client’s experience. The result was a
strengthening in the bond between the clinician and client as the client felt the comfort
of being understood. This interaction opened the door to addressing the client’s
experience of illness and the meaning it had for her. The client no longer felt that
the clinician was “pushing” her agenda onto the client. Eventually, the client was able
to negotiate with the clinician and her psychiatrist a medication regime that she the
client felt comfortable with.
Boundaries
Clinicians have an obligation to put client needs before their own and to act in the
client’s best interests. “Sometimes, our own conscious or unconscious wishes make
it hard to recognize boundary violations” (rnao, 2002). A very important function
of individual clinical supervision is the development in the clinician of an awareness
and understanding of the boundaries and limits of the professional role. This understanding
of boundaries is crucial to providing safe and ethically sound clinical
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practice. Within a safe and trusting relationship, the clinician can explore the client’s
thoughts and feelings related to the client, and discuss behaviours that may indicate
the crossing of boundaries, such as spending extra time with clients, having special
clients, or doing activities with clients that the clinician does not share with colleagues.
In this way, clinical supervision is a proactive process that can prevent boundary
transgressions. Proctor (1991) refers to this function of clinical supervision as “normative.”
Normative supervision is concerned with promoting high quality care and
reducing risks. The supervisor is obligated to confront any situation or practice he
or she feels is unethical or unsafe. As mentioned previously, an ideal process is one
in which the supervisor facilitates the clinician to identify the problem and initiate
corrective action.
Transference, countertransference and parallel process
As supervision moves beyond the initial stages of developing trust and safety, a more
in-depth understanding of the client is achieved by exploring the processes of transference,
countertransference and parallel process. Transference refers to a process in
which the client transfers past or present attitudes and feelings toward family members
or other important persons in their life onto the clinician. It may be positive or negative
and, in classic psychoanalytic literature, is described as an unconscious phenomenon.
Clients may repeat interaction patterns characteristic of earlier relationships in their
relationship with the clinician. The client’s transference is important to explore with
the clinician as it contributes to greater understanding of the client’s difficulties. For
example, one might speculate that the client in the first vignette developed a negative
transference toward the nurse responding to her like a critical parent may have in
the past. The nurse, feeling as though she was “nagging” the client, and the client’s
subsequent withdrawal from the relationship, supports this notion.
Countertransference refers to thoughts and feelings experienced by the clinician toward
the client. Countertransference may also be experienced by the supervisor toward
the clinician, and by the clinician toward the supervisor. Similar to transference, these
feelings may be positive or negative. Before any exploration of countertransference,
it is crucial that there be a trusting relationship between clinical supervisor and
clinician. The clinical supervisor must also be cognizant of maintaining the boundaries
of the supervisory relationship. “The guiding principle is that all discussion
relates to the client. If the supervisor or supervisee sees a drift towards exploration
of factors relating to the supervisee’s relationships and life apart from reactions
to and feelings about the client, the supervisor should stop, rethink, and consider
alternatives.” (Falender, 2006, p. 39)
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Parallel process refers to changes in the supervisor-clinician relationship that relate
to dynamics in the clinician-client relationship; in other words, it involves a series
of transference-countertransference interactions. The supervisor needs to be alert to
changes in the clinician’s mood or behaviour, as well as feelings within him- or herself.
Such changes may indicate that a parallel process is taking place (Gallop, 2004).
Grey and Fiscalini (1987) note that the motivation for the clinician engaged in parallel
process with the clinical supervisor is that by acting like his client he is trying to
communicate information not consciously accessible, or that he is trying to see how
the clinical supervisor would handle the situation.
An example is described in the following vignette.
CASE EXAMPLE: TRANSFERENCE AND
COUNTERTRANSFERENCE
A social worker was involved with a client on an inpatient unit,
and his wife. He described to the clinical supervisor the conflict
this couple was experiencing and the events that led up to a
restraining order being issued by the court prohibiting the husband
from having any contact with his wife. This followed a physical
assault by the husband. The social worker described his experience
of working with this client and the couple. The husband
and wife, although physically apart, continued to communicate
indirectly through the social worker. He found himself in the role
of intermediary between the wife and the husband. As the social
worker described the relationship and his involvement as an
intermediary, the supervisor began to find it difficult to follow.
She had to frequently seek clarification from the social worker as
his communication became increasingly convoluted and she
becoame increasingly confused. She shared her confusion with
the clinician and asked if this was how he was feeling in his work
with this couple.
This led to a discussion of the social worker’s role with this couple,
including the boundaries of his role, and the couple’s conflict,
ambivalent feelings and hidden agenda that seemed to be getting
played out through the social worker. Afterward, the clinician felt
less burdened and was able to focus more clearly on the boundaries
of his role with this couple and set clear limits. He also
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recognized the limitations of his professional involvement and
more clearly understood what could realistically be achieved with
this couple during a brief inpatient stay.
Authority and dependency issues are frequently at the root of parallel processes
(Grey & Fiscalini, 1987). If the clinical supervisor and clinician don’t explore
motivations for engaging in this process, they may get stuck in a series of transferencecountertransference
interactions. Grey and Fiscalini (1987) state that this is avoided
if the clinical supervisor empathizes with the clinician, but does not get stuck in
the empathic process. The clinical supervisor is able to see the client and clinician’s
perspectives, and differentiate them from his or her own. The supervisor is then able
to clarify the transference-countertransference interplay occurring. However, if the
clinical supervisor does get caught up in a parallel process, he or she can use his or
her own emotional response to explain the anxiety in the clinician-client dyad and,
additionally, the anxiety in the supervisor-clinician dyad.
Exploring transference, countertransference and parallel process as they emerge
within the supervisory relationship and clinician-client dyad ultimately illuminates
a deeper, more meaningful understanding of the client.
Conclusion
Individual clinical supervision, when conducted in the context of a supportive, trusting
relationship, is a vital process that contributes significantly to quality client care.
As the clinician’s capacity to engage in reflective practice grows, so too does his or
her ability to establish therapeutic relationships with clients. The supervisory process
is a journey that clinical supervisor and clinician embark on together. It is a journey
that in so many ways models the clinician-client relationship by introducing experientially
concepts critical to the development of healthy and therapeutic relationships
with clients such as empowerment, empathy, trust and boundaries. The supervisory
process and the client are better understood through discussions of transference,
countertransference and parallel process as they emerge along the way. While taking
time out of one’s busy schedule to participate in or conduct clinical supervision
may at times seem challenging, this is time well spent, particularly when one sees
the positive outcomes for clients, the therapeutic impasses that are overcome, and
the boundary transgressions that are avoided.
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A CASE PRESENTATION MODEL
FOR CLINICAL SUPERVISION
Presenting a case to a supervisor and / or colleagues helps clinicians organize information
about treatment into coherent themes and concepts. It also gives the clinical
supervisor a chance to evaluate which areas of practice and client management the
clinican has mastered and which could be improved or enhanced (Ask & Roche,
2005) There are many ways that case presentations can be structured. The following
section describes the approach used by one camh program.
Using the Core Conflictual Relationship Theme
The clients of a camh program that provides inpatient and outpatient transitional
care treatment for women with a mood disorder associated with a history of interpersonal
trauma (childhood and/or adulthood physical, emotional and/or sexual
abuse often experience the consequences of trauma including substance abuse, selfharm
behaviour and dysfunctional interpersonal relationship patterns. Because they
experience these problems within their relationships, the Core Conflictual Relationship
Theme (ccrt) and the consideration of feminist themes are used as frameworks to
enhance clinicians’ understanding of the client’s dynamics.
Luborsky (1997) believed that the ccrt was a valuable approach to setting treatment
goals in short-term hospital settings. It provides a way of both clinicians and clients
increasing their understanding of the client’s relationship difficulties and ways of
overcoming them. The ccrt method is based on the principle that redundancy across
relationship narratives is a good basis for assessing the central relationship pattern.
A relationship pattern consists of:
• the person’s wish in relationships
• what they experience as the reaction of others (RO) to them
• how they respond to these reactions (the reaction of self (RS).
People generally approach relationships with a wish for something particular from
the other person (e.g., the wish to be loved, validated or generally cared for). They
experience others responding to them in particular ways (e.g., loving, abusive, silencing)
and they react in kind (e.g., withdraw, push the other person away in anger). Through
describing different relationships, the clinician and client can see patterns emerge.
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The pattern is the ccrt (e.g., the client yearns to be loved and noticed but finds that
most people in her life are abusive in different ways. She reacts by withdrawing and
thus experiences loneliness and isolation).
Using the ccrt as an organizing framework, the clinician preparing to present his or her
client would come to the clinical supervision session with the following information:
• client’s initials
• number of sessions (when the client being presented was part of an outpatient
program) or date of admission for inpatients
• identifying data
• age
• history relevant to concerns client is expressing
• relationship experiences/status
• issues related to diversity
• client belief system
Provisional ccrt
Wish 1: to be heard and validated for who she is, to have a sense of self, to be able to
establish more effective boundaries
RO (response of others) 1: ignore her, tell her what to do, beat, humiliate or
abandon her
RS (response of self to others’ reaction) 1: feels angry, withdraws, feels like she
cannot make her own decisions and relies on others to do so, feels depressed, pushes
people away, feels silenced
Wish 2: to be taken care of (if I were wealthy, I could live the kind of life I want)
Associated feminist themes: violence, patriarchy, powerful feminine figures (goddess,
grandmother), emphasis on appearance as a measure of worth
RO 2: “You are stupid.” “You do not deserve to live.” “You cannot do what you want
to do (travel, dance).”
RS 2: not take advantage of opportunities, withdraw, “I am too tired to make changes,”
“I am stupid” pushes people away by being difficult to be with or saying she does not
want to commit
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In addition to the above, clinicians in this program consider information related to
traumatic re-enactments. With this comes the understanding that a common feature
in these clients’ relationships are the roles of perpetrator, victim and rescuer and
how the client can assume these roles interchangeably with others in their lives based
on their childhood experiences. This includes their relationships with clinicians.
After presenting this information to the clinical supervisor and the group, the team
and the clinician working with the client have a better understanding of the underlying
dynamics and can use this to help the client look at alternatives and make sense
of how this pattern continues to be problematic.
Adapted from Luborsky, L. (1997). In T. D. Eells (Ed.), Handbook of Psychotherapy Case Formulation: The Core
Conflictual Relationship Theme. New York, NY: The Guilford Press.
SPONTANEOUS CLINICAL SUPERVISION:
CLINICAL SUPERVISOR AS LIGHTHOUSE
Using the lighthouse as a metaphor for the clinical supervisor presents the image
of a steady beacon for temporarily lost and stranded ships in the fog. The clinical
supervisor can provide direction, guidance and support for safe passage when it is
most needed. The lighthouse connotes a symbol of leadership, assurance, safety
and hope.
In the busy life of a program, it’s important to consider how adhering to a too-rigid
definition of clinical supervision may be a barrier to staff receiving important support
in their work. Requests for clinical supervision can come in many forms. Important
supervision issues, especially in an inpatient setting, often arise spontaneously and,
although it may be unrealistic to expect that the supervisor can provide a totally
comprehensive supervision in a short time (within 10 to 20 minutes), unscheduled
conversations about client care can be consistent with a traditional definition of
clinical supervision. These conversations may also be a starting point for more formal
supervision. Supervisors should be encouraged to consider multiple, brief clinical
conversations that include Socratic questions, affirmation of the supervisee’s skills
and capacities, and promoting client-centred care within a program—as very real
examples of clinical supervision. In other words, the sum of multiple effective contacts
can equal or exceed one scheduled formal session.
If supervision is limited to scheduled conversations, many opportunities for responding
to staff needs for consultation will be lost. Staff needs for support, education and
guidance cannot be totally addressed without this more open access to the clinical
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supervisor. Access to the supervisor can be a good way for staff members to flag
issues as they arise and to sort out which ones need to be addressed in the moment
and which ones warrant a more full exploration in scheduled supervision.
In the realm of established and formal clinical supervision, one could argue whether
“clinical supervision on the fly” or “spontaneous clinical supervision” has validity.
Given a culturally diverse staff makeup, along with varying degrees of competency
levels, some staff members may seek spontaneous clinical supervision while others
prefer scheduled supervision. Historically, many nursing staff have come to associate
scheduled supervision with disciplinary action. In such a context, spontaneous
supervision provides a mechanism for clinicians to introduce supervision issues
ahead of time. This may be less of a concern for newer nursing graduates with more
experience at receiving formal supervision than for nurses who may have begun
practising at a time when supervision was associated with discipline. Currently,
nurses receive mentorship during their training and expect it from designated senior
colleagues or their direct supervisor.
Another way of viewing spontaneous clinical supervision is as a vital component
of the life of an inpatient unit in which traditional, scheduled supervision may not
be realistic. Some of the benefits of spontaneous supervision can include reduction
of feelings of isolation on the part of staff and alleviation of feelings of anxiety that
may arise during the work day. One observable factor when assessing how staff
members learn is the use of self-reflection, which might be more familiar for the
allied health professionals. This may be new to some nurses, who might view it
as a luxury they do not have time for. Nurses working on inpatient units are often
expected to work at a fast pace, and at times may feel that stopping for reflection
means that they are putting a greater workload on others or are short-changing the
immediate physical needs of their clients.
Critical support in the areas of education and administration is provided when it
is needed. When guided, staff are able to use independent critical thinking through
process and analysis. The clinical supervisor lets staff problem-solve, which promotes
confidence in their ability to function and provide effective service in the moment
and may help to reduce any possible fears of “admitting a mistake.” Professional
growth is observable through attitude change and a positive perspective toward
learning while doing. As one nurse remarked: “there is a sense of renewed hope, which
fosters a sense of belief in myself.” There is no greater motivator than someone
acknowledging your worth as a clinician, as a colleague and as a person. Open recognition
of excellent performance can bring a much-needed smile to even the most
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isolated staff member. On the floor it can be seen that clinicians shine with a simple
gesture of thanks, “great work on capturing near-misses,” “what a tremendous work
on that eIPCC” or “great job on assisting that client with transition.”
In addition to the support and guidance provided to staff, the supervisor responding
to these spontaneous requests is modelling clinical skills and techniques important
to the development of therapeutic relationships with clients, such as flexibility, availability
and support. Being flexible and available to staff demonstrates an approach
that clinicians can translate into their relationships with clients. The challenge for
the supervisor is knowing when to back off or redirect staff to scheduled sessions.
If staff are only using these spontaneous opportunities and not engaging in more
formal supervision, then the supervisor may want to explore with the staff the possibility
of setting time aside in advance to discuss clinical practice issues.
Spontaneous clinical supervision is not a brief “quick-fix, give-me-the-answer-now”
interaction. It involves critical educational, emotional and clinical support, which
can open the door for follow-up sessions, in which fuller discussions of clinical
scenarios and dilemmas contribute to the growth of the staff member. Spontaneous
supervision does not replace a more traditional model of supervision but offers a
starting point by engaging staff, is flexible and responsive to the needs of staff working
in a busy program, and can also provide an adjunct to traditional supervision.
CASE EXAMPLE: SPONTANEOUS SUPERVISION
A clinical supervisor on a long-term care inpatient unit was
approached by the charge nurse, who wanted to take time from
her busy day to visit a patient who had been transferred to a general
hospital for medical investigation. She understood that it
would mean turning the charge nurse responsibilities over to
another nurse for that time, but felt that it was important to
respond to the perceived needs of the individual patient. She did
not have a regular clinical supervision time scheduled for that
morning but showed up at the clinical supervisor’s door to
discuss her plan and its implications. The clinical supervisor
provided support and assisted her in developing and following
through on the plan.
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The nurse did go to visit the patient and when she returned,
again, flagged down the clinical supervisor because she felt the
need to discuss the case. She reported that her clinical intuition
(although she did not use that term) that a visit by her was needed
was accurate. Because she knew the condition of this patient
so well, she was able to help the staff arrive at the diagnosis of
pneumonia and to provide emotional support for a very ill
patient. This led to a discussion of a recent personal loss for this
nurse and her fears for the future of her patient. This second conversation
only took a matter of 10 to 15 minutes (the nurse needed
to get back to provide noon medications) but in it the clinical
supervisor was able to affirm and support a dedicated staff member
for her clinical assessment and care.
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SPECIAL ISSUES
Interdisciplinary Clinical Supervision
In many therapeutic settings, clinical supervision works with groups that include
staff from many different disciplines. At camh, a nurse educator (NE) and an advanced
practice clinician (apc) regularly provide interdisciplinary clinical supervision in a
longer-term unit within the Schizophrenia Program for an inter-professional staff
made up of registered nurses (RNs), registered practical nurse (rpns), social workers,
occupational therapists and recreational therapists. In this section on special issues,
we will start with their experiences.
We would like to begin with two apparently contradictory thoughts. The first is a
quote that was attributed to H.G. Wells. He called professions the “enemy of the
people.” While one wouldn’t necessarily give much thought to the philosophies of
H.G. Wells, the apc heard it in the context of a conference on recovery, in which
professions were being presented as a way in which professionals distance themselves
from their clients and get into unnecessary conflicts with their colleagues. The second
comes from something heard by the apc from a wise supervisor whose professional
training was in social work. She said that every time she felt certain that she understood
nursing she would find that something that the nurses were pointing out as
a big problem was something that she would not have noticed at all. The apc knows
what she means; when providing clinical supervision with the NE, she will ask a
question about nursing clinical practice and it will take her several minutes to understand
what the NE is referring to and why, but the nurses get the importance of it
immediately and the apc eventually does.
So which approach is right? Is it that the divisions between the professions create
unnecessary gulfs between us, making it impossible to really see and care for our
clients, or is it that we need to become more aware of our differences and more
appreciative of one another’s strengths? The NE and the apc have found that it
is both.
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In a busy inpatient unit, clinical supervision goes on all the time. The rhythm of the
day cannot be determined in advance. Beginning first thing in the morning, either
the NE or the apc can be stopped by staff with questions about client care and clinical
practice. At first they would just try to answer quickly, and that still happens at
times, but these ongoing questions provide opportunities for discussing clinical care.
It becomes clear very quickly that the NE and apc will each have slightly different
takes on what needs to happen. That might be a problem except for the respect that
each of them feels for the other—both for the unique clinical perspective that the
other brings to each issue and the trust they have in each other’s caring for clients
and staff. And they cannot stress enough that they also bring shared values for
reflective, client-centred care.
There have been times when a nurse wonders aloud to the NE about the apc’s
understanding of their workload. The message that she gives is that the apc can
appreciate and respect their contribution even if she is not a nurse. This confidence
from the NE in the abilities of a social worker to lead nurses sends a reassuring
message that they have the same goals and values in their work.
So what are the important qualities that make interdisciplinary clinical supervision
work, and even work so well as to bring qualities that are greater than the sum of
one nurse and one social worker? As already discussed, awareness and appreciation
of each other’s professional knowledge base and the trust that each brings the best
of these to her work are important. Implied in that is respect. When either one of
them speak, the other listens and they make this clear to staff. In this way they model
professional respect, including respectful communication, to their staff.
STRENGTHS OF THE CLINICAL STAFF
In planning clinical supervision, both the NE and apc spend time reviewing the
strengths of individual staff members, as well as the strengths inherent in professions
they represent. While each profession makes unique contributions to the clients,
there are large areas of overlap, especially in terms of values and goals for clients.
On this particular client care unit, the social workers are the champions of reflective
practice and the big picture of client care; the occupational therapists understand
what clients need to be able to function well in the community; the recreation therapists
are masters at getting clients active after years of inactivity; and the nurses shine
in areas that can seem like a bit of a mystery to the others—what used to be called
patient management, and is now thought of as core nursing practice. As a social
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worker, the apc often listens in admiration to the attention nurses give to the physical
side of client care. As a nurse, the NE expresses appreciation for the initiative and
willingness of the rest of the staff to address all aspects of a client’s life.
STAFF CULTURAL DIVERSITY AND
ITS IMPACT ON CLINICAL SUPERVISION
After joining the team, the apc immediately saw the richness of culture on the unit.
The majority of the nursing staff either comes directly from or is descended from
Africa, the Caribbean or South Asia. The apc with the assistance of the NE, have
sought to distinguish and identify the cultural differences and norms within the team.
This has helped in valuing the wisdom in culturally specific traditions, practices,
beliefs and expectations. For example, the apc realized after establishing a working
relationship with the nursing staff that some of the nurses come from a cultural
background where a one-to-one meeting with a supervisor is culturally acceptable;
by contrast, others prefer and seek the benefit of a “group meeting/supervision” to
find the guiding wisdom of the “elder.”
CONTEXT OF INTERDISCIPLINARY SUPERVISION
The nurse educator was already providing supervision and leadership on this particular
unit when the apc arrived. They immediately began individual training in the
new electronic plan of client care, the eIPCC. Some of the nurses expressed apprehension
about this training. They felt that their typing and computer skills were
lacking and that the new apc would not respect them. Instead, the apc wanted to
talk about the electronic plan of care as a tool for expressing caring and concern
for clients, beginning with common ground, not technical limitations. The apc was
accustomed to using supervision time to support reflective practice and incorporated
it into the training. She found that some nurses were familiar with this approach
but that there were others for whom the questions the apc would ask opened a new
door to nursing care.
For example, “Client lacks insight into their illness” was a common issue presented
in the plan of care. It might be thought that exploring the meaning of this issue with
the client was providing clinical supervision from a social work perspective. This
introspective approach to clinical supervision has been championed by social workers.
By including it in the training it opened the door to reflection, to looking at the care
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for the client, and the goals for his or her future, with a wider and deeper lens than
simply making the goal “Client will gain insight into his or her illness.” Why would
that be our goal? What would the client gain from it? Would the client gain anything
from it? Sometimes using oneself as the example will bring insight: Why would it be
important for me to gain insight into my asthma? How would that help my health or
advance me as a human being?
This led to deeper conversations about the needs of individual clients. It seemed
especially important for the nursing staff, some of whom seemed to believe that they
did not have the right to be that involved in their client’s inner life. The importance
of the nurse educator’s support for this approach by the apc cannot be overstated.
Her vote of confidence for this interdisciplinary approach gave the nurses permission
to develop their clinical skills.
An important part of what makes this partnership work so well is the support of both
the manager and the physicians in the program. Everyone in leadership positions on
this particular unit is “on the same page” when it comes to supporting client-centred
care, clear communication and ethical clinical practice. In daily interactions and
clinical directions large and small, the NE and apc feel confident that their work will
be supported.
INTERDISCIPLINARY SUPERVISION IN PRACTICE
The nurse educator and the advanced practice clinician are often in the position of
working together on staff leadership. Here is a typical example of a situation in which
the two professions are greater than the sum of their parts. In dealing with a conflict
between two nursing staff members, both the NE and the apc each gravitated toward
different but equally important questions regarding clinical practice. The apc asked
each person to reflect on contributions she might be able to make to improve the
situation. The NE focused on clinical responsibility, asking the RN charge nurse / team
leader how she communicated client assignments. Each asked a different version of
the same question but each elicited different and helpful answers, and together they
gave a full picture of how each person approached their professional practice.
Many staff members on the unit have worked in positions in which professions have
been separate and sometimes competitive. Bringing clinical supervisors from two
different professions together to provide clinical supervision to staff from several
professions means providing an opportunity for staff to appreciate the strengths and
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gifts of their colleagues, to learn from one another and improve co-operation in
providing service to their clients.
Nursing and Clinical Supervision
Providing clinical supervision with nurses offers challenges that are unique, particularly
when their work is on inpatient units. As noted earlier, nurses’ experience with
clinical supervision and the meaning attached to it can be different from how social
workers and psychologists see it. For nurses, clinical supervision is often associated
with management rather than clinical practice. For example, nursing supervisors
focus more on operational issues and provide support to staff nurses in the absence
of managers on evenings, nights and weekends around issues such as staffing and
transferring clients between units and to other hospitals.
REFLECTIVE PRACTICE
“Reflective practice” is more familiar terminology than “clinical supervision” for
nurses. As members of their professional college, nurses are required to demonstrate
that they have engaged in reflective practice to maintain licensure. This entails being
attuned to the nurse’s own professional needs and ensuring that they obtain the
necessary continuing education to practice competently. Within the college and
university systems, nurses are often asked to reflect on situations with clients in
terms of how they responded, how they understood what went on in light of their
readings/literature, and what alternatives they would consider based on their synthesis
of this information. Analysis of transference and countertransference (see p. 61)
are not generally part of the reflection. A mental health and addiction rotation is
currently not a requirement in training for all undergraduate nursing programs. For
example, one university in Toronto places nursing students at camh in the context
of a “community” experience instead of the more traditional psychiatry placement.
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EXPLORING NURSE’S PERCEPTIONS OF CLINICAL
SUPERVISION
Cleary and Freeman (2005) explored nurses’ perceptions of clinical supervision relative
to other professional support opportunities in acute inpatient mental health settings.
They found that nurses valued having a supportive forum to air their concerns in a
non-judgmental, collegial way, and to discuss practice issues with peers, such as issues
around boundaries with clients. They also viewed dialogue and sharing with their
peers as an opportunity to “reflect on and develop clinical skills” (p. 494). Although
many nurses were aware of the advantages of clinical supervision and supported it in
principle, many preferred informal, ad-hoc approaches with their peers. Most found
it difficult to find the time for clinical supervision, particularly individual clinical
supervision, on a busy, acute care unit and questioned its feasibility. Instead, “informal
support with one’s peers was seen to be more responsive to the clinical realities
of everyday work as generally colleagues were available and accessible” (p. 495).
The clinical supervisor can use this knowledge to help nurses look at the similarities
and differences between what they obtain through these informal means of support
and peer supervision, and what formal clinical supervision can provide. Nurses on
one inpatient unit at camh have identified that although peer support is valuable, it
does not always help them to process their feelings. Hearing others share that they
have had similar feelings and experiences can be validating, but it does not assist
them in seeing connections to their previous personal experiences, wishes or social
location. Sometimes nurses identify with one another’s feelings of powerlessness in
working with a client, making it difficult to gain the objectivity to move beyond
these feelings. The risk of relying on peer support alone is that the status quo may
be maintained and alternative approaches or ways of understanding a situation may
not be considered.
PRACTICAL ISSUES
More than other disciplines, nurses on inpatient units rotate shifts. This makes
consistent attendance at group clinical supervision sessions more difficult. To
accommodate their schedules, the group clinical supervision happens in open rather
than closed sessions. This can have an impact on group cohesion when membership
changes from session to session. Given the high turnover of clients on inpatient
areas, the focus of the clinical supervision tends to change from session to session
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rather than staff being able to talk about particular clients over an extended period
of time. One way of attending to this, particularly given the “revolving door” nature
of hospital admissions, is to provide time to discuss clients who are re-admitted as
an opportunity to learn from their previous stays. This underlines the importance of
the clinical supervisor being flexible and available to address the issues that can arise
on an inpatient unit spontaneously on a day-to-day basis. This is further discussed
in Spontaneous Clinical Supervision: Clinical Supervisor as Lighthouse, p. 66.
Nurses on inpatient units have 24-hour responsibility for their clients and no separate
office space. On one unit they described feeling as though they are in a fish bowl,
constantly being observed and accessible to clients in a way that other professionals
are not. This makes boundary setting with clients more challenging. Nurses may feel
powerless because they feel they have less control over their environment.
Nurses usually see clients when the clients are in crisis. They are less likely than other
members of the team to see clients at other stages in their lives such as when they are
functioning in the community. Nurses attend to a broad range of clients’ needs that
include physical as well as emotional needs, and are involved in tasks such as providing
medication, restraining clients, caring for wounds and establishing a therapeutic
relationship. This places nurses within the client’s personal space in ways that are
quite different from other disciplines. This is an important difference for the clinical
supervisor to consider.
PREPARATION
Since nursing staff may not be familiar with the process of clinical supervision, clinical
supervisors should provide education up front about what clinical supervision is and
is not in order to develop a “safe” environment where nurses are willing to disclose
their practice challenges. The preparation includes:
• acknowledging their unique position on the team and how that affects their
client interactions
• differentiating between the procedural activities that are the focus of
administrative supervision
• explaining the differences between therapy and clinical supervision to reinforce
the respect for appropriate boundaries between the clinical supervisor and
the nurse.
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The clinical supervisor explains that the focus is on the professional development
of the nurse in the context of his or her work with the client, rather than on the
development of action plans for the nurse’s personal problems. In other words, the
focus is on the nurse’s process and behaviour with the client. The clinical supervisor
explains that clinical supervision is an opportunity for nurses to turn what they
know and feel into skillful action by paying deliberate attention to their experience,
and critically analyzing feelings and observations. The intended outcome is a new
perspective on a situation that they initially found puzzling or surprising.
A Multi-Method Professional
Development Approach in
Daily Practice
INTEGRATED CARE AND BUILDING CAPACITY IN
THE SCHIZOPHRENIA PROGRAM
In order to support staff to practice new skills and reflect on how it will change clinical
practice, staff members have needed supervision and coaching to increase their
confidence and knowledge base to address concurrent disorders. One of the camh’s
strategic directions focuses on providing integrated care to clients. Best practice literature
suggests that program integration means:
[M]ental health treatments and substance abuse treatments are
brought together by the same clinicians/support workers, or team of
clinicians/support workers, in the same program, to ensure that the
individual receives a consistent explanation of illness/problems and a
coherent prescription for treatment rather than a contradictory set of
messages from different providers. (Health Canada, 2001, p. vii)
Consequently, the clinical staff continues to develop skills to address how addictions
and mental health impact each other when working with clients.
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Historically, clients were sent to specialized programs that separated mental health
and addictions. In the Schizophrenia Program, many of the staff participated in
trainings to address concurrent disorders. The staff has been working toward providing
integrated care. While many staff members are addressing these issues regularly,
some also express the concern that maybe “I could be doing more” as a clinician.
W.R. Miller et al. (2006) note that “to learn any new behavioural skill, people need
not only informational training but also:
• clear and accurate feedback regarding their performance
• guidance from a supervisor / coach who has greater expertise and proficiency in
the skill.
Without performance feedback, significant change in practitioner behaviour does
not occur.” (W.R. Miller et al., 2006, p. 35) While trainings provide clinicians with a
foundation around theory, there is a lack of confidence expressed by staff members
in their ability to provide integrated treatment. They say that they need ongoing
practice to develop skills in developing concurrent disorders treatment.
Coaching/Partnering Style of Supervision—
A Motivational Interviewing Approach
An approach to clinical supervision has been used to help staff members develop
their clinical skills around concurrent disorders. This approach involves coaching
and gives clinicians an opportunity to work with the clients who are actively using
substances. The clinical supervisor uses a motivational interviewing approach that
promotes a coaching rather than instructional style. Clinical supervisors model and
teach motivational interviewing approaches in the way that they work with the clinician,
as well as the client. The coach communicates to the clinician that ambivalence
is expected when clients are considering changing their substance use patterns, and
that clients choose whether or not to make a change. Typically clinicians seek out
this support from the supervisor when clients are in an early stage of treatment
and may be starting to consider making a change in their substance use (e.g., the
engagement or persuasion stage of treatment). These stages are defined by Mueser
et al., 2003, pp. 123-124).
During this process, the role of the clinical supervisor evolves from one of cofacilitator
and role model to observer as the clinician develops the skills and confidence
needed to provide integrated care. Initially, the clinical supervisor may be more
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engaged with the client, but over time steps back. The supervisor role is explained to
the client so that she or he knows that the primary relationship is with the clinician.
The clinical supervisor and clinician usually contract that every four sessions they
will evaluate and decide whether to re-contract to continue the process. The client
is also consulted about the length of involvement to see if this matches his or her
goal for treatment. The clinical supervisor asks for written evaluations from the
clinician to assess the usefulness of this role. The clients have also been asked to fill
out evaluations on their experiences. This approach has been used primarily for
individual sessions.
Group supervision
When the clinical supervisor is involved in coaching/supervising staff in co-facilitating
a group on concurrent disorders, the contract is usually for a longer time period.
The focus in this setting is to help staff develop skills needed to work with clients
presenting with concurrent disorders issues. Some clinicians may also need help with
developing group facilitation skills. For example, a clinical supervisor and clinicians
work together to develop a handbook that would guide the staff in facilitating sessions.
The long-term goal for the clinical supervisor is to step back, observe and provide
feedback until the clinicians decide they are ready to continue facilitating the group
on their own. The clinical supervisor often becomes more of a clinical consultant as
needed, rather than a supervisor or coach.
Community of practice
Beitler (2005) discusses the idea of a community of practice as a group of like-minded
clinicians who are interested in exploring and developing skills in a specific practice
area. He notes:
The primary focus is the sharing of experiences and new ideas that
members can use in practice. Key themes include a domain of common
issues, developing a sense of community that includes trust and
a social bond, and the element of practice. The majority of the members
must be seasoned practitioners who are bringing their issues,
ideas, advice and applying this knowledge to their practice, and then
reporting back their experiences (pages 1, 7–8).
(Beiter, M.A. (2005). “Strategic Organizational Learning.” Greensboro,
NC: Practioner Press International. (pp. 70-77)).
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Beitler indicates that the co-ordinators do not have to be the leading experts in the
field, but do need to be passionate about the knowledge domain and be well respected.
One such project has been a pilot of a Motivational Interviewing Community of
Practice. These sessions provide opportunities for people with more advanced training
in motivational interviewing to practice skills through participation in role plays,
watching videos and discussing challenges in their practice. This process of learning
gives clinicians an opportunity to review best practice literature, learn from each
other and practice skills. Peers take responsibility for the sessions. The early sessions
have been organized and co-facilitated by a group of clinicians who are experienced
in the area of motivational interviewing and have provided training in this area. This
project is in its beginning phase. Initial evaluations have been positive. Clinicians
are invited to participate in planning and continuing the developing of this learning
initiative. In addition, a practice is being developed with staff members who are less
experienced in motivational interviewing in the Schizophrenia Program. The staff
are working to apply the recovery model and want to practice skills of motivational
interviewing. Staff may have less experience with motivational interviewing, but would
like to develop skills; share knowledge and challenges; and develop confidence in their
practice. In the near future, as this project continues, there may be access to a listserv
to help people share articles, discuss clinical challenges and network around motivational
interviewing issues.
Concurrent disorders journal club
These journal clubs started out as a way to share best practices on integrated care.
This learning is not clinical supervision but a way of sharing information based
on readings from the book Treating Concurrent Disorder: A Guide for Counsellors
(Skinner, 2005). This six-session group is held monthly and is facilitated by one or
two staff members who specialize in concurrent disorders. Each month one of the
authors comes to discuss his or her chapter. The meeting focuses on comments,
thoughts, and questions related to the chapter (e.g., motivational interviewing, family
issues, youth and setting up group programming). The clinicians are asked to evaluate
this learning experience at the end of the cycle. Approximately 10 people are involved
in each journal club.
An advanced journal club has evolved in response to people’s participation and
interest in further learning. In this group, guest speakers focus on a topic related to
concurrent disorders best practices guidelines. Clinicians share clinical scenarios
and request feedback. This format is continuing to evolve as the clinicians suggest
learning ideas. As staff develop their skills and confidence in working with clients
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that present with concurrent disorders issues, they are providing leadership in facilitating
and organizing the journal clubs. As stated by Miller, et al. (2006), “a persistent
novice golfer on a driving range can gradually learn how to drive a ball farther, but
learning can be substantially accelerated by a little coaching from an experienced
professional” (pp. 35-36).
Ethical Considerations in
Clinical Supervision
Because the clinical practice environment is becoming more complex, clinicians are
bringing clinical scenarios to supervision sessions that defy neat and tidy resolutions,
thus challenging clinical supervisors to tread ethical paths they may have never
encountered in their own front-line careers. For this reason, a new emphasis has been
placed on the importance of ethics training for all clinical supervisors, no matter how
much clinical experience they have to inform their work with clinicians.
Frederic Reamer, a professor of social work in the United States, has done extensive
work on ethical considerations in clinical practice and supervision (Reamer, 1994,
1999, 2001, 2003). He emphasizes that it is crucial for clinical supervisors to have
the skills and background necessary to develop in their clinicians a way of thinking
ethically, since it is not possible to have hard and fast rules about many of the dilemmas
encountered in clinical practice. This way of thinking involves ethical decision-making,
which takes into account conflicting values and duties, identifies individuals and
groups likely to be affected by a certain decision, and tentatively identifies all possible
courses of action with possible risks and benefits. In addition, Dr. Reamer’s approach
examines reasons for and against each possible course of action. He recommends
that ethical theories, principles and guidelines; codes of ethics; legal principles;
discipline-specific practice theory and principles; personal values; and agency policies
and regulations all be used to inform the examination.
In a 14-week graduate social work course at Rhode Island College, Dr. Reamer
covers a wide range of “key risk areas,” which he maintains are taken into account
by good quality clinical supervision. The areas include:
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Ethical Considerations in Clinical Supervision
• client rights
• confidentiality and privacy
• informed consent
• service delivery
• boundary issues and conflicts of interest
• documentation
• defamation of character
• client records
• supervision
• staff development and training
• consultation
• client referral
• fraud
• termination of services and client abandonment
• practitioner impairment
• evaluation and research.
STANDARD OF CARE
Dr. Reamer points to the principle of “standard of care,” which he defines as “what
an ordinary, reasonable, and prudent professional, with the same or similar training,
would have done under the same or similar circumstances.” He considers this the
most important sentence in clinical supervision. It can guide discussion of complex
clinical dilemmas. Dr. Reamer cites two types of standards of care.
• A “substantive” standard of care is one that is widely accepted across clinical
practice settings, for instance, the norm that dating clients is indefensible on
ethical grounds.
• “Procedural” standards of care cover processes that are invoked with difficult,
ethically complex scenarios—cases in which experienced clinicians and practice
leaders commonly disagree about what constitutes the best course of action.
Activities that encompass procedural standards of care include consulting with
colleagues and supervisors; reviewing relevant ethical standards; reviewing relevant
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laws, policies and regulations; reviewing relevant literature; obtaining legal consultation
when necessary; consulting an ethics committee, if available; and documenting
decision-making steps.
ETHICAL CONSIDERATIONS: AN EXAMPLE
It is beyond the scope of this guide to cover the depth and breadth of what ethical
training clinical supervisors require. However, it may be helpful to consider a common
clinical issue in which ethical considerations figure prominently. Client discharge
or termination provides a good example. In many instances, clinicians may struggle
with decisions to discharge a client before he or she has completed a treatment
program. This struggle may involve weighing the circumstances that precipitated the
potential discharge against an appreciation of the client’s significant ongoing needs.
If the decision to discharge is carried out, Dr. Reamer recommends the following
guidelines to protect clients and minimize risk:
• Provide clients with names, addresses and telephone numbers of at least three
appropriate referrals.
• Follow up with a client who has been terminated. If the client does not go to
the referral, write a letter to him or her about relevant risks.
• Provide as much advance warning of the termination as possible.
• When clients announce their decision to terminate prematurely, explain the
risks involved and suggestions for alternative care. Include this information
in a follow-up letter.
• Carefully document in the case record all decisions and actions related to
termination.
• In cases involving discharge from residential facilities, prepare a comprehensive
discharge plan and, with client consent, notify significant others.
• Provide clients with clear instructions to follow in the event of an emergency.
Ask clients to sign a copy acknowledging that they have received the instructions
and that the instructions were explained to them.
• Consult with colleagues and supervisors about termination strategy and decisions.
• Consult relevant code of ethics standards.
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Evaluating Clinical Supervision
Evaluating Clinical Supervision
Although clinical supervision is regarded as an important factor in enhancing client
outcome in mental health and other human service settings, there is limited research
support for the effectiveness of clinical supervision (Strong et al., 2003). In particular,
there has been a call for research in the following areas:
• evaluating supervisory training
• examining diversity issues in clinical supervisor-clinician relationships and in
various service settings
• exploring the impact of clinical supervision on client outcomes (Bruce & Austin,
2000).
Some recent exploratory research addresses key areas related to evaluating the clinical
supervision context and supervisor skills. Areas that have been addressed include:
• core competencies in supervision (Falender et. al., 2004)
• diversity / cultural competence in supervisors (Armour et al., 2004)
• benefits and barriers to effective clinical supervision (Strong et al., 2003)
• trainee preferences in clinical supervisor feedback (both positive and negative)
(Heckman-Stone, 2003).
This section will summarize these findings and will provide a number of concrete
suggestions for evaluation approaches and tools that can be used in clinical supervision.
The section will conclude with a brief discussion of the importance of documenting
supervision in clinical settings—an area that has been identified as being of key legal
and ethical importance (Falvey & Cohen, 2003). Note that performance evaluation
of clinicians is not addressed in this section, as it falls outside of the purview of
clinical supervision camh, and is already carried out annually using approved
protocols and tools.
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Core Competencies in
Clinical Supervision
Falender and colleagues (2004) recently published a consensus statement on core
competencies in psychology supervision. This was done in response to recommendations
arising from an international working conference held in 2002. The primary
aim was to identify areas of consensus and difference in a variety of research and
practice domains, including clinical supervision. (For more information about conference
topics and membership, see Falendar et al., p. 773.) Falender and colleagues
note that identifying competencies helps move professions from normative (or subjective)
assessments to criterion-based (or objective) assessments. This approach has
the advantage of introducing greater rigour to the clinical supervision process as well
as to the performance and techniques of individual supervisors. A brief overview of
these core competencies sets the stage for a discussion of what we might evaluate in
clinical supervision, and how this can be best carried out.
Although the competencies outlined below were developed in reference to the
discipline of psychology, they are broadly applicable and relevant to other clinically
focused disciplines such as social work, nursing, medicine, psychiatry, occupational
and recreation therapy. Clinical supervisor competencies have been divided into six
general categories, with a number of micro-skills within each area. The broad competencies
of knowledge, skills, values, social context / overarching issues, training
and assessment are summarized in Table 1. The final area, assessment, is particularly
relevant to evaluation of clinical supervision. Note that the wording of the discrete
micro skills has been somewhat adapted to better reflect clinical practice at camh.
TABLE 1: SUPERVISION COMPETENCIES AND MICRO-SKILLS
COMPETENCY AREA MICRO SKILLS
1. Knowledge • Knowledge of area being supervised
• Knowledge of relevant models, theories, interventions and
research
• Knowledge about clinicians’
• Learning and professional development
• Knowledge of ethical and legal issues relating to supervision
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Core Competencies in Clinical Supervision
COMPETENCY AREA
MICRO SKILLS
• Knowledge of clinical outcome and process evaluation
• Knowledge and awareness of diversity, marginalization and
oppression issues and diversity competence
2. Skills • Supervision methods
• Relationship skills (building a supervisory alliance)
• Sensitivity to multiple roles with supervisee and able to balance
multiple roles
• Ability to provide constructive and effective feedback
• Ability to promote supervisee self-assessment and growth
• Ability to conduct own self-assessment process
• Ability to assess supervisee’s learning needs and developmental
level
• Ability to encourage and use evaluative feedback from
supervisees
• Teaching skills
• Ability to set appropriate boundaries and seek consultation/
supervision (assess own competence)
• Flexibility
• Integrating and presenting evidence-based practice and
best practice principles
• Documentation procedures
• Ability to impart evidence-based practice knowledge within
the supervisory session
3. Values • Supervisor is accountable for supervision provided—to
supervisee and to client
• Respectful
• Responsible for diversity awareness and competence
• Balance between support and constructive feedback/
challenging
• Empowering
• Commitment to continuous learning and professional growth
• Balance between clinical and training needs
• Valuing ethical principles
• Knowing and using supervision research and best practices
• Committed to knowing own limitations
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Clinical Supervision Handbook
COMPETENCY AREA
MICRO SKILLS
4. Social context / • Diversity
overarching • Ethical and legal issues
issues
• Developmental process
• Knowledge of organization and expectations re. clinical
supervision
• Awareness of socio-political context within which supervision
is conducted
• Creation of climate in which authentic, honest feedback is
the norm (both supportive and challenging feedback)
5. Training in • Continuing education in supervision knowledge and skills
supervision • Receives supervision of supervision, including observation
competencies (videotape/audiotape/in vivo observation with critical
feedback)
6. Assessment of • Successful completion of supervision course / workshop
supervision • Documented evidence of supervision of supervision, noting
competencies readiness to supervise independently
• Evidence of direct observation
• Documented evidence of supervisory experience reflecting
diversity competence
• Documented supervisee feedback
• Self-assessment and awareness of need for
consultation / supervision when necessary
• Assessment of supervision outcomes
• Impact of client outcomes
Adapted from Falender et al., 2004, p778
Based on the micro-skills outlined in competency number six, assessment of
supervisor competencies, evaluation of clinical supervision should ideally incorporate
the following elements:
• Certificate of completion of some form of continuing professional education
(e.g., course, workshop) in clinical supervision
• Documentation that the supervisor has had supervision that focuses on his or her
role as supervisor, and recommendations (with follow-up and development plan)
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Core Competencies in Clinical Supervision
• Clinical supervisor self-assessment (reflective practice) (e.g., through attendance
in a supervisors’ supervision group, or through openness to learning from and
implementing evaluation feedback by supervisees)
• Evidence of diversity competence (e.g., completion of camh diversity training,
other measures of diversity / cultural competence, which can be used with both
supervisor and supervisees)
• Clinical supervisor evaluation (completed by clinicians)—both process and
outcome (e.g., using the Supervision Feedback Scale (Heckman-Stone, 2003),
discussed on page XX in this section)
• Link to client outcomes—possibly via the Interdisciplinary Plan of Client Care
(ipcc) if possible.
BENEFITS AND BARRIERS TO
EFFECTIVE CLINICAL SUPERVISION
In order to better understand the clinical supervision context, its strengths and areas
for improvement, Strong and colleagues used focus groups and brief interviews to
explore clinical supervision practice among allied health professionals in a large
mental health service. The focus group questions, which closely mirrored the questions
used in the brief interviews, can provide a useful, semi-structured guide for
carrying out periodic process evaluations of clinical supervision groups. The questions
asked included:
• What do you see as the benefits of supervision?
• What would you regard as ideal supervision in your profession?
• What do you see as the best aspects of current supervision practices in your
employing organization?
• In what ways is current supervision less than ideal?
• What are the main barriers to good supervision in mental health service?
• What issues have been raised by your experiences with cross-professional
supervision?
• What are the three most important things that need to be done to improve
supervision practice? (Strong, et al., 2003, p. 195)
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If a culture of authenticity and honesty is fostered in clinical supervision groups,
periodically reflecting on the process of clinical supervision can lead to valuable
insights and enhanced effectiveness of the supervisors. The research found that clinical
supervision was a key to improving clinical competence and implementation of best
practices, as well as a source of support for staff. The main barriers identified were
the absence of a clear organizational policy on clinical supervision and failure to
allocate sufficient resources to support clinical supervision practice. Articulating a
model of clinical supervision and a training agenda were also seen as primary issues.
It may be interesting and illuminating to compare the experiences and perceptions
of camh clinicians with the findings of Strong and his colleagues (2003).
EVALUATING DIVERSITY COMPETENCE IN CLINICAL
SUPERVISION
The issue of diversity competence has been identified as being of key importance in
clinical supervision, and is reflected in a number of the core micro-skills of clinical
supervisor competencies noted above. As Divac and Heaphy (2005) point out,
“developing cultural competence is now a requirement for achieving appropriate
professional standards in therapy and supervision training” (p.282). Diversity is a
factor not only in working with clients, but in the heterogeneity of supervision groups
and dyads as well. Thus, diversity competence is relevant in clinical supervisors’
feedback around case formulation and intervention, and in power dynamics, experiences
of privilege/oppression/marginalization, and working across difference in the
clinical supervision context. There is a small but growing literature focused on the
development, application and evaluation of diversity / cultural competence in clinical
supervisors (Armour et al., 2004; Constantine et al., 2005; Divac & Heaphy, 2005).
Evaluation tools
A number of tools have been developed and validated for use by instructors, clinical
supervisors and/or clinicians. These range from brief process evaluations to more
extensive summary evaluations. These tools may help clinical supervisors to assess
their own competence in this area.
Armour et al. used a closed-ended, 13-item, self-administered questionnaire and
anonymously written responses to five reflecting questions in a repeated measures
design. (A copy of the closed-ended questionnaire is included in Armour et al.’s
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Core Competencies in Clinical Supervision
article as an appendix, p. 38.) Both clinical supervisors and clinical supervision
groups could use this tool to periodically assess progress in diversity competence,
and to stimulate discussion about areas for professional and personal growth.
The questionnaire addressed comfort with diversity; awareness of issues of power,
control and interpersonal conflict; and knowledge about oppressed groups. The
added open-ended reflecting questions included:
• highlights in practitioners’ diversity training experiences
• peak enjoyable or disturbing experiences (or both) in diversity training
• an idea or skill supervisors could use with supervisees
• how supervisors’ insights (facilitated by their responses to previous questions)
could contribute to their effectiveness in supervision
• actions that supervisors could take to enhance the cultural competence in their
agency or program. (Armour et al., 2004, p. 34)
The study showed significant gains in diversity awareness in the period between the
end of the training and follow-up. Clinical supervisors also noted areas for further
development in improving supervision practice, including normalizing discomfort,
awareness of retreating from exploring diversity, and permission to address “socially
taboo” topics.
Divac and Heaphy (2005) suggest that ongoing feedback and reflection in supervision
of supervision sessions is an important formative evaluation strategy for diversity
competence. They also suggest that semi-structured interviews with trainee supervisors
should be carried out at the end of the academic year. (The content of the interviews
was not yet developed by the authors at the time of publication of their article.)
Divac and Heaphy describe the content and format of monthly sessions for clinical
supervisors, where the specific focus was on fostering diversity competence. This
approach may be of particular relevance to the professional development of clinical
supervisors due to its richness in process and experiential emphasis. In this model,
trainee supervisors meet one day per month to discuss key issues, skills and abilities
in cross-cultural practice. Divac and Heaphy note that the main focus is on the
process and experience of engaging with subjective assumptions, biases and experience
related to their own and others’ cultures. In addition, trainees use the group format
to reflect on diverse aspects of their identities, which may be privileged in some
contexts and disadvantaged in others. Finally, group sessions are videotaped and
reviewed to encourage continued reflection and exploration of issues.
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In another study, Constantine, Warren and Miville (2005) present and discuss the use
of the multicultural case conceptualization ability exercise, a tool and coding system
used to determine the extent to which clinicians are able to integrate salient cultural
issues into two different conceptualizations of a client case.
Finally, Pope-Davis and colleagues (2000) describe the development and validation
of the Multicultural Environmental Inventory—an instrument designed to measure
the degree to which graduate counselling programs address multicultural issues in
their curricula, clinical supervision, climate and research. The instrument was condensed
from 53 to 27 items based on the results of factor analyses, and showed promise
in its ability to assess change over time, as well as good validity and reliability. Although
designed for academic settings, it may be useful to test either the instrument as a whole,
or the supervision subscale, as a way to evaluate clinical supervisors’ effectiveness in
addressing and promoting cultural competence in clinical supervision groups.
Cultural and diversity competence is now being addressed in a more rigorous fashion
in clinical supervision settings. This reflects a growing awareness of their importance,
and of the need for ways to assess and identify gaps in knowledge and skills (both in
clinical supervisors and in front-line clinicians).
CLINICAL SUPERVISOR EVALUATION
Providing and accepting clear and concrete feedback, identifying strengths and areas
for improvement, and specific concerns with respect to good clinical care can be
difficult for both clinical supervisor and clinician. Yet “when supervisees reflect on
their supervision, what comes to mind most often is the quality and quantity of
feedback they received” (Bernard & Goodyear, 1998). Therefore, clinical supervisors
need to evaluate the extent to which they are providing constructive and salient
feedback to clinicians.
Heckman-Stone (2003) carried out a pilot study with 40 graduate students from
three training programs (counselling psychology, clinical psychology and masters
degree in counselling). She used a scale of 10 items rated on a seven-point, Likert-type
scale, where 1= strongly disagree, 4 = neutral, and 7 = strongly agree. In addition,
the author included four open-ended items designed to elicit examples of positive
and negative feedback in clinical supervision, and the characteristics of good
and poor use of feedback and evaluation by clinical supervisors. An example of
the instrument, adapted for use with more experienced clinicians—as opposed to
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Core Competencies in Clinical Supervision
students—is presented below. Based on the results of the pilot study, Heckman-
Stone outlines a number of recommendations in providing feedback to clinicians.
These include:
• Begin by describing the process of supervision.
• Set clear, mutually agreed upon performance criteria.
• Reliably observe the supervisee’s work.
• Compare the observations with performance objectives/criteria.
• Have supervisee provide a self-evaluation first.
• Start with positive evaluations.
• Specify the skill area being addressed in giving the feedback.
• Have supervisees set the agenda for supervision sessions as much as possible.
• Monitor supervisees’ use of feedback and evaluation.
The Clinical Supervision Feedback Scale can be used as either a process or outcome
evaluation for clinical supervisors to assess their skills in providing feedback, and
identify areas for development. Another structured clinical supervision evaluation
instrument, the Group Supervisory Behavior Scale (gsbs, White and Rudolph, 2000)
has also been demonstrated to have good reliability and validity, and may be useful
in evaluating supervisor behaviours in group supervision contexts.
CLINICAL SUPERVISION FEEDBACK SCALE
(1 = STRONGLY AGREE; 4 = NEUTRAL; 7 = STRONGLY AGREE)
1. My supervisor welcomed comments about his or her 1 2 3 4 5 6 7
style as a supervisor.
2. My supervisor’s comments about my work 1 2 3 4 5 6 7
were understandable.
3. I didn’t receive timely information about how 1 2 3 4 5 6 7
I was doing as a therapist. [reverse scored]
4. I have had written feedback from my supervisor 1 2 3 4 5 6 7
about my clinical work.
5. My supervisor balanced his or her feedback 1 2 3 4 5 6 7
between positive and negative statements.
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Clinical Supervision Handbook
6. The feedback I received from my supervisor 1 2 3 4 5 6 7
was based on his or her direct observation of my work
(including video / audiotapes).
7. The feedback I received was directly related to 1 2 3 4 5 6 7
the goals I set in supervision.
8. There were inconsistencies between my supervisor’s 1 2 3 4 5 6 7
feedback to me in session and written feedback.
[reverse scored]
9. I am satisfied with my supervisor’s use of feedback 1 2 3 4 5 6 7
in session.
10. I am satisfied with my supervisor’s written feedback. 1 2 3 4 5 6 7
Open-ended items:
11. Please describe a positive experience you have had 1 2 3 4 5 6 7
with feedback in supervision.
12. Please describe a negative experience you have had 1 2 3 4 5 6 7
with feedback in supervision.
13. Please list characteristics of good use of feedback 1 2 3 4 5 6 7
by your supervisor.
14. Please list characteristics of poor use of feedback 1 2 3 4 5 6 7
by your supervisor.
Adapted from Heckman-Stone, 2003, p.28.
DOCUMENTATION OF SUPERVISION
IN CLINICAL SETTINGS
The importance of documentation in clinical supervision cannot be overstated, and
is an important source of evaluative feedback to clinicians. As Falvey and Cohen state:
Keeping records is standard practice for virtually all human services
and medical disciplines. From a legal as well as an ethical perspective,
if it isn’t documented, it didn’t occur. The question for supervisors,
then, is not whether to document, but how to do so in an efficient
manner. (Falvey et al., 2003, p. 77)
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Core Competencies in Clinical Supervision
The authors note that over-documentation can be as much an issue as under-documentation,
and suggest the use of structured forms to capture case review data and
recommendations. Falvey et al. also strongly recommend that clinicians not be given
sole discretion in selecting cases for review in clinical supervision. They note that
clinicians may not recognize important practice issues in all cases, and that significant
client care problems or issues may not be addressed unless all cases are periodically
reviewed. As the authors state:
Leaving the choice of which cases to review up to the supervisee, while
commonplace, is not an ethically or legally viable supervisory practice.
Evaluation anxiety, concern over clinical errors or boundary violations,
negative reactions to the supervisor, or failure to recognize the
importance of clinical signs and symptoms contribute to a high rate
of supervisee nondisclosure. (Falvey et al., 2003, p. 72)
Falvey and Cohen also highlight the importance of a clinical supervision contract,
records of all clinical supervision sessions (with details on cases discussed and
decisions made); notes on cancelled or missed supervision meetings, and on significant
conflicts in clinical supervision sessions and how they were handled. These documents
can assist in identifying training/professional development needs, and provide
“evidence of competent supervision should a supervisee grievance or client lawsuit
subsequently arise” (Falvey & Cohen, 2003, p.68). They present samples of forms
developed as part of a clinical supervision process evaluation/tracking package, titled
the Focused Risk Management Supervision System (FoRMSS). (The authors provide
sample forms in their article; see pages 73, 74 and 76.) These forms (or FoRMSS) can
be adapted for use in clinical supervision groups as a way of maintaining a record of
case discussions and a process evaluation of clinical supervision issues and outcomes.
Conclusion
Evaluation of clinical supervision is a complex and challenging task. However, it
is crucial to fostering transparency, accountability and modelling of best practices.
Areas for further research identified in the literature include evaluating/assessing
clinical supervisors’ diversity competence, and demonstrating the impact of clinical
supervision on client care outcomes. The latter may be facilitated by more active use
of the Interdisciplinary Plan of Client Care (ipcc) in clinical supervision sessions,
where ipcc goals and outcomes are routinely discussed as part of the case review
and clinical feedback process. In the absence of clear and unequivocal empirical
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Clinical Supervision Handbook
support for best practice tools in clinical supervision assessment and evaluation,
these preliminary instruments and scales should be regarded as a starting point in
introducing greater rigour and accountability into the clinical supervision context.
FIGURE 2: INTERDISCIPLINARY PLAN OF CLIENT CARE (IPCC) FORM
Available in pdf and Word versions on Insite:
http://insite.camh.net/forms/clinical_forms/10258_interdisciplinary_plan_of_client_care.html
96

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APPENDIX 1
Conceptualization of Clinical
Supervision: A Review of the Literature
SOCIAL WORK
Supervision in social work is essentially conceived of as a method to ensure the
organization’s mandate is achieved by enhancing the supervisee’s* ability to provide
effective service. The supervisor is accountable for the job performance of agency
workers (Kadushin, 1976; Kadushin & Harkness, 2002) with administrative, educational
and supportive activities being used to achieve this goal. Supervision scholars in
social work agree on the importance of a positive relationship between supervisor
and supervisee as the context for learning and performance (Barretta-Herman,
1993; Kadushin & Harkness, 2002; Munson, 2002; Shulman, 1993, 2005) while
emphasizing the parallel process in the working relationship between client-worker
and worker-supervisor.
Three interrelated functions of supervision were proposed by Kadushin (1976)
—administrative, educational and supportive—a conceptualization that has continued
to receive support (Bruce & Austin, 2000; Munson, 2002; Shulman, 1993).
Administrative supervision encompasses selecting and orienting workers/clinicians;
assigning cases; and monitoring, reviewing and evaluating work. It serves as a
socializing agent, advocating, and buffering within the organization. Agencies grant
supervisors authority to direct others’ work and they use both formal power such
as rewards, coercion, position in the organization, and informal power derived from
their expert knowledge and relationships with their supervisees.
*The term supervisee is used in this section to maintain consistnecy with the literature.
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Educational supervision encompasses activities that develop the professional capacity
of supervisees, including teaching knowledge and skills, and developing self-awareness
(Barker, 1995; Munson, 2002) through, for example, teaching, case consultation,
facilitating learning and growth. Kadushin and Harkness (2002) note that in the
general social work supervision literature, the term clinical supervision frequently
refers to a focus on the professional practice of the supervisee. Others associate clinical
supervision with an analytic focus on the dynamics of the client situation and the
worker’s interventions and interactions with clients (Gibelman & Schervish, 1997).
We prefer the definition of clinical supervision in professional psychology, which
includes both enhancing the professional performance of the junior member of the
profession while monitoring the quality of services offered to the client (Bernard
& Goodyear, 2004). Supportive supervision encompasses helping workers handle
job-related stress by providing appropriate praise and encouragement, normalizing
work-related reactions, affirming strengths and sharing responsibility for difficult
decisions (Kadushin & Harkness, 2002). Stress is related to the emotional demands
on social workers faced with traumatic and acute social problems that may be
challenging to articulate within the supervision setting (Barretta-Herman, 1993).
Supportive comments are meaningful when given within the context of a relationship
with a respected and valued supervisor (Kaiser & Barretta-Herman, 1999).
In an analysis of themes in the supervision literature, Bruce and Austin (2000) predict
that supervisors in the future would need to incorporate the following: change
management skills including understanding the multiple governmental, community
and organizational contexts of practice; practice in racially and culturally diverse
organizations and communities; use of client outcomes to monitor service delivery;
and processes that promote effective inter-professional work.
In summary, this review of the literature found a view of supervision for social work
that includes the interrelated elements of administration, education and support.
Each of these factors influences all of the others and, when operating in concert,
produce more effective services for clients. Separating educational or clinical elements
from this holistic definition distorts the fundamental essence of social work supervision.
Similar to principles of effective practice, supervision is an interpersonal and interactional
process between worker and supervisor. The importance of offering and
modelling positive elements in a supportive, performance and outcomes-oriented
relationship is reinforced in the literature.
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Conceptualization of Clinical Supervision: A Review of the Literature
Toward an evidence-base for clinical social work supervision
Does the research on social work supervision provide evidence to support this
conceptual model and related principles and practices? Two recent reviews of the
empirical research on social work supervision, one spanning 1970–1995 (Tsui, 1997)
and one spanning 1994–2004 (Bogo & McKnight, 2005) uncovered a dearth of studies
in this regard. The existing studies used small sample sizes, used exploratory, survey
and cross-sectional designs; and contributed modestly to theory-building or providing
evidence for best practices. The studies reviewed, however, did offer some support
for some elements identified in the conceptual literature. For example, Erera and
Lazar (1994) found supervision consisted of the three major functions: administrative,
educational and supportive. A number of studies investigated the organizational
context of supervision and found that the agency’s mandate and focus shape the nature
of supervision provided (Berger & Mizrahi, 2001; Gibelman & Schervish, 1995,
1997; Gleeson & Philbin, 1996). Organizational climate affects supervisors’ and staff
performance and is positively associated with an environment that emphasizes task
orientation, staff involvement, autonomy and clarity of rules (Eisikovits et al., 1985).
Organizational climate also affects satisfaction with greater levels of trust among
colleagues associated with higher satisfaction in child welfare (Silver et al., 1997).
The influential nature of the supervisory relationship was supported (Hensley, 2002).
Administrative, educational and supportive aspects were valued by supervisees and
seen in behaviours such as availability, delegated responsibility to supervisees who
can undertake a task (Granvold, 1978; York, 1996), are knowledgeable about tasks
and skills (Drake & Washeck, 1998; Himle, et al., 1989), are able to relate techniques
to theory (Drake & Washeck, 1998), provide instrumental support (Himle et al., 1989)
and serve as a role model (Drake & Washeck, 1998; Hensley, 2002). General support
was associated with higher worker satisfaction (Newsome & Pillari, 1991; Rauktis &
Koeske, 1994). Workers were more satisfied when they perceived supervisors’ use of
authority as based on their knowledge and skill rather than their middle manager
role (Munson, 1993) and when supervisors communicated in a mutual style (Bowers,
et al., 1999; York & Denton, 1990).
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References
Barker, R.L. (1995). Social work supervision. In Social Work Dictionary. Washington, DC: NASW Press.
Barretta-Herman, A. (1993). On the development of a model of supervision for licensed social work
practitioners. The Clinical Supervisor, 11 (2), 55–64.
Berger, C. & Mizrahi, T. (2001). An evolving paradigm of supervision within the changing health care
environment. Social Work in Health Care, 32 (4), 1–18.
Bernard, J.M. & Goodyear, R.K. (2004). Fundamentals of clinical supervision (3rd ed.). Boston, MA:
Pearson.
Bogo, M. & McKnight, K. (2005). Clinical supervision in social work: A review of the research literature.
The Clinical Supervisor, 24 (1/2), 49–67.
Bowers, B., Esmond, S. & Canales, M. (1999). Approaches to case management supervision.
Administration in Social Work, 23 (1), 29–49.
Bruce, E.J. & Austin, M.J. (2000). Social work supervision: Assessing the past and mapping the future.
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Drake, B. & Washeck, J. (1998). A competency-based method for providing worker feedback to CPS
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Eisikovits, Z., Meier, R., Guttman, E., Shurka, E. & Levinstein, A. (1985). Supervision in ecological context:
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Gibelman, M. & Schervish, P. H. (1995). Pay equity in social work: Not! Social Work, 40 (5), 622–629.
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Munson, C.E. (1993). Clinical Social Work Supervision (2nd ed.). Binghamton, NY: Haworth Press.
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Newsome, M. & Pillari, V. (1991). Job satisfaction and the worker/supervisor relationship. The Clinical
Supervisor, 9 (2), 119–129.
Rauktis, M.E. & Koeske, G. F. (1994). Maintaining social worker morale: When supportive supervision is
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Silver, P.T., Poulin, J.E. & Manning, R.C. (1997). Surviving the bureaucracy: The predictors of job
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York, R.O. (1996). Adherence to situational leadership theory among social workers. The Clinical Supervisor,
14 (2), 5–24.
York, R.O. & Denton, R.T. (1990). Leadership behavior and supervisory performance: The view from below.
The Clinical Supervisor, 8 (1), 93–108.
NURSING
Scholars in nursing practice have noted that the multiple definitions, models and
organizational structures create more confusion than clarity in understanding clinical
supervision (Clearly & Freeman, 2005; Cutcliffe & Lowe, 2005; Jones, 2003; Kelly et al.,
2001; Yegdich, 1999).
Definitions
Clinical supervision in nursing means different things to various organizations and
the people they employ (Rizzo, 2003) and it becomes difficult to find one definition
that captures all the key elements (Cutcliffe & Lowe, 2005). Butterworth and Faugier
(1992) define clinical supervision as “an exchange between practicing professionals
to assist the development of professional skills” (p. 12). Clinical supervision is also
defined as “a practice-focused professional relationship involving a practitioner
reflecting on practice, guided by a skilled supervisor” (UKCC 1996, p. 4).
Jones (2005) reviewed research literature on clinical supervision and credits Winstanley
and White (2003) with the most comprehensive definition: “focusing upon the
provision of empathetic support to improve therapeutic skills, the transmission of
knowledge and the facilitation of reflective practice. The participants have an opportunity
to evaluate, reflect, and develop their own clinical practice and provide a
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support system to one another” (p. 8). She further identifies the following aspects of
supervision that have achieved agreement by nurse educators:
• It is a formal growth-focused relationship.
• It provides an opportunity for the supervisor to review the professional
development of a new practitioner.
• It provides a forum for discussing the practice of care.
• It allows colleagues to learn from and encourage each other.
• It reduces professional isolation, emotional strain and stress.
• It may lead to the development of practice theory. (Jones, 2005)
She adds that clinical supervision in the United States is also known in clinical
settings as “the relationship between the nursing staff and an administrative clinical
staff member. This relationship is primarily supportive and evaluative in function
and does not meet the criteria for clinical supervision as defined in the UK” (p.149).
In summary, these definitions, though varied, describe a process in which the supervisee
and the supervisor discuss issues related to the supervisee’s practice, development
and, to some extent, performance.
Models
Sloan (1999) notes that there is no one model of supervision that can deal with the
diversity of clinical needs found in nursing. Differences in definition, models and
the practice of clinical supervision reflect cultural differences between countries,
organizations and nursing specialties. They also reflect differences between North
American and European conceptualizations of clinical supervision.
In North America, clinical supervision refers to relationships between an administrator
or a superior and a more junior supervisee with the supervisor having supervisory
responsibility for the performance of the supervisee (Cutcliffe & Lowe, 2005).
In Europe, clinical supervision emphasizes professional development and support
for the practitioner (Gilmore, 2001). It also focuses on supervisee-led issues that
range from patient care to interpersonal issues with peers (Cutcliffe & Lowe, 2005).
Similarly Jones (2005) refers to the U.K. model as a mandatory reflective practice
between the supervisee and the supervisor, while in the United States, the model
refers more to a relationship between an expert supervisor and a novice or new
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nurse supervisee.
Additionally Jones (2005) identifies the three models of clinical supervision found in
the nursing literature:
• the growth model and support model (Faugier, 1992)
• the integrative approach (Hawkins & Shohet, 1989)
• the three function-interactive model (Proctor, 1986).
Growth model
In the growth model, the supervisor facilitates growth both educationally and personally,
assisting in developing clinical autonomy in the supervisee. The focus is on the
relationship aspect of clinical supervision and includes mentorship (Faugier, 1992).
Integrative model
The integrative model divides supervision into four components: supervisor, supervisee,
client and work context. The supervisor and supervisee develop a contract with
negotiated shared tasks and goals (Hawkins & Shohet, 1989).
Three-function interactive model
Proctor’s (1986) three-function interactive model is based on a normative or managerial
function, which promotes and complies with organizational policies. Educational
supervision encompasses activities that develop the professional capacity of supervisees,
including teaching knowledge and skills, and developing self-awareness (Barker, 1995;
Munson, 2002) through, for example, teaching, case consultation, facilitating learning
and growth. This educational component and the restorative or pastoral support
function help the nursing practitioner to understand and manage the emotional
stress of nursing practice.
In the ideal working environment, these models of clinical supervision present benefits
for nursing practice. For instance, several studies have shown that nursing staff
who access clinical supervision acquire a greater readiness to act as well as a greater
openness to change attitudes and outlooks when it comes to:
• solving problems that arise in care relations (Begat et al., 1997; Magnusson et al.,
2002)
• co-ordinating their responses with others (Jones, 2003)
• experiencing greater job satisfaction (Arvidsson et al., 2001; Hyrkäs, 2006)
• improving creativity and organizational climate (Berg & Hallberg, 1999).
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Toward an evidence-base for clinical supervision in nursing
Does the research on clinical supervision in nursing provide evidence to support the
diverse conceptualizations? Two reviews of the empirical research on clinical supervision
in nursing, one spanning 1990–1999 (Williamson & Dodds, 1999), and the other
spanning 1996–2004 (Jones, 2005) found that different aspects of clinical supervision
are widely studied and described in the nursing literature. This growing interest in
clinical supervision, however, derives mainly from Europe (U.K. and the Scandinavian
countries) and from Australia and New Zealand. There is a paucity of research from
North America (Cutcliffe, 2005; Jones, 2005). The studies reviewed employ surveys
and exploratory interviews with descriptive and systematic qualitative designs and
have begun to contribute to an empirical base. However, investigators note that these
studies address the concept of clinical supervision in nursing while lacking a consensus
about the definition of the term or its components (Yegdich, 1999).
The existing studies contribute to the formation of a definition and all provide
support for its utility. For example, Kelly and colleagues (2001) found that managers
(87.5 per cent), supervisors (85.2 per cent), and the great majority of clinical
psychiatric nurse respondents supported the view that supervision can lead to
personal development.
Studies examined the process of clinical supervision. In one study, it was found that
a focus on the nurse “doing” (defined as the nurse-patient relationship) and not on
the nurse “being” (defined as the nurse as a person) made it easier for nurses to talk
about their feelings and actions (Berg & Hallberg, 1999). A number of studies found
that clinical supervision helps nurses gain knowledge and competence, a sense of
security in nursing situations, and a feeling of personal development (Arvidsson et al.,
2001; Jones, 2003; Magnusson et al., 2002). Additionally, Arvidsson and colleagues
(2001) found that supervision gave nurses a sense of feeling independent, increased
energy, fellowship with others and greater job satisfaction.
Format of clinical supervision
The format of clinical supervision has been investigated by a number of researchers.
In a study of nurses in an acute inpatient mental health setting, Cleary and Freeman
(2005) found nurses preferred ad hoc coping methods such as informal sharing and
support of trusted colleagues rather than a more formal approach. These nurses felt
that one-on-one clinical supervision was impossible due to unit constraints. Clinical
supervision in open groups was difficult to arrange due to staff leaves, rotations and
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skill mix. In contrast, Kelly et al., (2001) found that one-on-one clinical supervision
was the commonly adopted approach by three-quarters of their sample of nurses
in Northern Ireland. Group supervision was offered to only seven per cent of nurses
surveyed.
Factors contributing to quality of supervision
In investigating the factors that contribute to the quality of supervision, Berg and
Hallberg (1999) found that quality depended on the supervisor’s ability to encourage
and create a permissive atmosphere while Kelly and McKenna (2001) identified the
importance of training. They found that 100 per cent of managers and more than
90 per cent of supervisors and clinical psychiatric nurses strongly supported the
need for supervisor training. They also found an overwhelming majority of all
participants agreed that managers are not the best supervisors.
Rafferty, and colleagues (2003) used a modified Delphi method with expert clinical
supervisors to elicit their perceptions about the multi-dimensional aspects of clinical
supervision and to achieve some consensus about crucial components. They found
three main factors that contribute to effective supervision:
• professional support
• learning
• accountability.
Professional support refers to use of time, supervisory environment and mutuality in
the relationship. Supervisors demonstrated the value of supervision by maintaining
appointment times and defining supervision as part of the work. A positive supervisory
environment was defined as offering consistency, comfort, privacy and the absence
of inappropriate distractions. Relationships were built on mutual respect, choice and
negotiation of ground rules.
The second factor is learning, which refers to focus, knowledge and interventions.
Supervisors assist supervisees to articulate, reflect and make meaning of their activities,
which promotes safety and effective nursing care. Knowledge is enhanced when
supervisors elicit explanations and identify supervisees’ abilities and needs for professional
development, when they affirm appropriate practice, support professional
esteem, and encourage the continual need for achievable challenges.
The third factor is accountability, which refers to organizational support, recording,
and competency. The organization must provide the commitment and resources
to enable supervisees and supervisors to receive or offer appropriate supervision.
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A competent supervisor is conscientious about recording processes that specify
content, about knowing who has a right to access information, and recognizing what
constitutes good practice. The maintenance of personal reflective diaries enabled
supervisors to define their own needs for supervision, clarify expectations, and
further develop their skill in supervision.
In summary, clinical supervision researchers in nursing conclude that clinical supervision
is necessary for safe and effective nursing practice and can lead to personal
and professional development (Arvidsson, et al., 2001; Berg & Hallberg, 1999; Kelly
& McKenna, 2001; Rafferty et al., 2003). Nurses, managers and supervisors agree
that the process and format vary depending on the organizational context in which
clinical supervision takes place (Arvidsson, et al., 2001; Berg & Hallberg, 1999;
Jones, 2003; Kelly & McKenna, 2001). Commonly identified elements are:
• positive interpersonal relationships
• affirmation of appropriate practice
• deliberate scheduling of time and space
• reflection and provision of specific applied knowledge
• organizational support
• staff accountability.
CONCLUSION
A comparison of the social work and nursing literature on clinical supervision reveal
common elements in the approaches offered by Kadushin’s model of three interrelated
functions of social work supervision and Proctor’s three-function interactive model
of nursing supervision. Both models of supervision include an administrative,
supportive and educational component that can lead to increased accountability
and feelings of personal support.
A significant difference between social work and nursing supervision is the lack of
consensus about the definition of clinical supervision in nursing. What is more,
the logistical realities of nursing, including time away from clients, rotating shifts,
24-hour care and stringent time-oriented duties make it challenging to implement
clinical supervision within a nursing environment. By comparison, in many social
work agencies, the daily activities of social work are exempt from many of these
constraints and offer an environment more conducive to regularly scheduled clinical
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Conceptualization of Clinical Supervision: A Review of the Literature
supervision sessions. Finally, social work has a long history of valuing clinical supervision
as the crucial vehicle for professional development of the social worker. By
contrast, in nursing, it appears from the literature that clinical supervision is more
frequently viewed as an authoritarian and hierarchical activity that arises in response
to an error or indiscretion.
References
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study. Journal of Nursing Management, 9, 161–171.
Begat, I.B.E., Severinsson, E.I. & Bergen, I.A. (1997). Implementation of clinical supervision in a medical
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Butterworth, T, Faugier, J. (1992). Clinical Supervision and Mentorship in Nursing. London: Chapman
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Magnusson, A., Lützén, K. & Severinsson, E. (2002). Journal of Nursing Management, 10, 37–45.
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reducing stress: A review of the literature. Journal of Clinical Nursing, 8, 338–344.
Winstanley, J. & White, E. (2003). Clinical supervison: Models, measures and best practice. Nurse Researcher,
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APPENDIX 2
Evaluation For a
Clinical Supervision Group
PART A
YES NO
Are you currently in supervision elsewhere? ■ ■
If yes, how long have you been in supervision elsewhere? ■ ■
How many times have you attended the clinical supervision group? ■ ■
PART B
YES YES NO
DEFINITELY SOMEWHAT
1. The clinical supervision group has helped ■ ■ ■
improve my clinical practice.
If yes, please elaborate on how the clinical supervision group has helped your clinical
practice…
YES YES NO
DEFINITELY SOMEWHAT
2. The clinical supervision group makes me ■ ■ ■
feel more supported in my practice.
3. Through the clinical supervision group, ■ ■ ■
I have learned new ways to approach practice.
4. The clinical supervision group has increased ■ ■ ■
my self-awareness.
5. The clinical supervision group has helped me cope ■ ■ ■
with difficult situations.
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Clinical Supervision Handbook
YES YES NO
DEFINITELY SOMEWHAT
6. The clinical supervision group has helped ■ ■ ■
me look more objectively at my work.
7. Through attending the clinical supervision group, ■ ■ ■
I have developed skills in providing peer supervision.
8. I feel safe participating in the clinical ■ ■ ■
supervision group.
** If you said somewhat or no to the above question, can you suggest some ways that
would improve safety?
Please comment on the following:
9. What do you feel is missing from the clinical supervision group?
10. What advice do you have for the facilitators?
Developed by Kathy Ryan (2005) in consultation with Ruth Gallop
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APPENDIX 3
CLINICAL SUPERVISION CONTRACT
DATE: _______________________________
As clinician and clinical supervisor, we agree to the following:
• to work together to facilitate in-depth reflection on issues affecting
practice, so developing both personally and professionally to develop
a high level of clinical expertise.
• to meet on average once per week as a group for one hour.
• to protect the time and space for clinical supervision, by keeping to
agreed appointments and time boundaries. Privacy will be respected
and interruptions avoided.
• to provide a record for our employer, showing the times and the dates
of the clinical supervision sessions.
• We will work to the clinician’s agenda, within the framework and focus
negotiated at the beginning of each session. However, the clinical
supervisor reserves the right to highlight items apparently neglected
or unnoticed by the clinician.
• We will work respectfully, both of us being open to feedback about
how we handle the clinical supervision sessions.
We both agree to challenge aspects of this agreement that may be
in dispute.
As a clinician I agree to:
• prepare for the sessions, for example, by having an agenda or
preparing notes, videos, observation opportunities, audiotapes.
• take responsibility for making effective use of the time (including
punctuality), the outcomes and any actions I may take as a result
of clinical supervision.
• Be willing to learn, to develop my clinical skills and be open to
receiving support and challenge.
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As a clinical supervisor I agree to
• Keep all information you reveal in the clinical supervision sessions
confidential, except for these exceptions:
– You describe any unsafe, unethical, or illegal practice that you are
unwilling to go through the appropriate procedures to address.
– You repeatedly fail to attend sessions.
• In the event of an exception arising, I will attempt to persuade and
support you to deal appropriately with the issue directly yourself.
If I remain concerned, I will reveal the information only after informing
you that I am going to do so.
• At all times work to protect your confidentiality.
• Not allow procedural issues of the work to monopolize the clinical
supervision session.
• Offer you advice, support, and supportive challenge to enable you
to reflect in depth on issues affecting your practice.
• Be committed to continually developing myself as a practicing
professional.
• Keep a record of our clinical supervision sessions.
• Ask for feedback for the purpose of evaluating the clinical supervision
process.
• Use my own clinical supervision to support and develop my own
abilities as a clinical supervisor and clinician, without breaking
confidentiality.
Anything else?
Frequency of Meetings
Venue
Duration of Clinical Supervision Relationship
Next Review Date
Signed
(Clinician)
Signed
(Clinical Supervisor)
Thank you for completing this questionnaire!
Adapted from Bolton Primary Care Trust (2003). Clinical Supervision Guidance Document. Available at
www.bolton.nhs.uk/foi_pubscheme/policy_store. Accessed January 15, 2008
118

APPENDIX 4
Core Clinical Practice Competencies
This document has been developed to articulate the practice competencies required
by camh clinicians of all professional disciplines. Each discipline has unique
domains and standards of practice determined by a regulatory body and/or professional
association. All camh clinicians must maintain membership in good standing
in their college or professional association. This document is offered as a guide to
the essential competencies required of all professionals in the organization. Other
documents such as the camh Code of Conduct, camh Leadership Profile and camh
Values and Mission Statement also delineate expectations of camh staff. This document
is specifically intended for use by camh clinicians to improve clinical practice and
client care. It may act as a framework by which camh clinicians develop learning plans,
monitor practice, set career milestones, and create professional development goals. It
may also act as a guideline for reviewing competency at each level of development.
Additionally, it may be used by:
• camh staff involved in orientation of students and new staff
• clients and other people using camh services to better understand the various
levels of practice of camh clinicians
• apn /apc / discipline chiefs and program managers to create a context for guiding
and evaluating the practice of supervisees
• camh administrators to effectively distinguish, maintain and further refine
standards of practice of camh clinicians, and to support them in the hiring and
retention of individuals with the necessary knowledge and skills required to
meet the needs of clients.
This document has been organized along a continuum of practice in order to
acknowledge that clinicians acquire knowledge and skills over time and that practice
matures in recognizable and definable ways. In domains of practice common to all
mental health and addictions professionals—therapeutic relationships, assessment,
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Clinical Supervision Handbook
intervention, evaluation, professionalism, collaborative practice—these core
competencies provide common language about job and performance expectations.
Ultimately, the development of these competencies across the organization will ensure
that camh clinicians are current in providing clients with evidence-based practices.
Three distinct levels of practice are delineated and each level coincides with the
development of practice as clinicians continue to gain skill, knowledge and professional
wisdom. It is possible that one may practice at a higher or lower level in certain
domains but the level of practice is defined by where one most consistently practices,
keeping all areas in mind. The same levels are for use across disciplines, and each
discipline has its own body of work and expertise, so the skills and behaviours practised
at each level will be different for each discipline. Each level of practice builds upon the
previous one, with increasingly greater competency, proficiency and excellence in the
breadth and depth of practice. It is also written in such a way that each clinical program
can adapt it more specifically to the particular needs of their client population.
LEVELS OF PRACTICE
The levels of practice identified here are:
• competent practice
• proficient practice
• expert practice.
Competent practice
Competent practice is characterized by entry-level clinical knowledge and skill by
a clinician who has completed an accredited educational program of study. The
competent clinician requires ongoing clinical supervision in order to become
proficient in specific knowledge and skill areas.
Proficient practice
Proficient practice is characterized by specialized clinical knowledge and skill whereby
the clinician is practising at an autonomous or intermediate level (typically three
years of experience in a specialized mental health/addiction field). The proficient
clinician is a recognized role model, student preceptor, clinical resource and leader
demonstrating clinical mastery and commitment to achieving program goals while
continuing to seek improvement through clinical supervision or consultation.
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Core Clinical Practice Competencies
Expert practice
Expert practice is characterized by the ability to lead, direct, support and influence
clinical practice within the organization. This clinician possesses intuition and has
developed a specialized knowledge and skill level that is grounded in higher education
and practical experience (typically five or more years). The expert clinician teaches,
supervises and consults with other members of the health care team. He or she takes
on an active part in the achievement of program goals.
NOTE: The term “client” is used to inclusively refer to individuals and their families,
groups or communities serviced by camh clinicians. However, the “client” of the
expert clinician is often clinical staff functioning at competent and/or proficient levels
of practice or the organization itself. “Family” is whoever the client determines his
or her family to be.
DOMAINS OF PRACTICE
The following chart outlines the domains of practice required for clinicians at
camh. The domains are:
• clinician-client relationship
• family and social support
• professional autonomy and accountability
• embracing cultural diversity
• clinical assessment: interviewing, formulation, treatment planning and
documentation
• therapeutic interventions with clients, groups and families: practice,
documentation and case management
• anticipation and responding to rapidly changing situation
• program development, implementation and evaluation of care
• outreach
• teamwork, collaboration and partnerships
• ethical, organizational and legal accountabilities
• professional development and research
• consultation and education
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Clinical Supervision Handbook Core Clinical Practice Competencies
CORE CLINICAL PRACTICE COMPETENCIES
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Competent
Possesses entry-level clinical
knowledge and skill and has
knowledge and skill to implement
the competency in routine
practice in a variety of clinical
situations
Proficient Expert
Possesses specialized, advanced
clinical knowledge and skill and
practices autonomously across
a wide range of increasingly
complex clinical situations
Possesses expert knowledge,
skill and intuition and applies
the competency in the most
complex situations at various
levels within and across the
organization
DOMAIN OF PRACITCE LEVEL OF PRACTICE
Clinician-Client Relationship
• Understands that the therapeutic
relationship between
clinician and client is foundational
to effective mental
health and addiction practice
• Facilitates therapeutic relationships
with clients that:
– focus on trust, respect,
compassion, empathy and
• Demonstrates mastery in
effectively engaging in, maintaining
and terminating
therapeutic relationships
• Models therapeutic relationships
with clients and demonstrates
the same principles in
relationships with students,
staff and larger systems
• Engages in and role-models
excellence in therapeutic
relationships with clients as
well as professional relationships
with supervisees and
other staff
• Demonstrates high level of
self-awareness and able to not
only acknowledge own personal
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Clinician-Client Relationship
continued
Competent Proficient Expert
client strengths
– promote and provide biopsychosocial-spiritual
and
cultural comfort and
sensitivity to clients
– protect client confidentiality
– respect client autonomy,
dignity, privacy and rights
• Demonstrates self-awareness
of his or her beliefs, values,
social location and culture
and their influence on therapeutic
relationships
• Responds appropriately when
differences arise between self
and clients from diverse
groups
• Ensures that appropriate
boundaries between professional
therapeutic relationships
and non-professional
personal relationships are
maintained
• Recognizes when triggers
• Demonstrates high level of
self-awareness and an ability
to respond effectively to
transference and countertransference
issues
• Promptly and effectively
addresses any inequitable or
discriminatory behaviours
toward clients, families and
others at camh
• Advocates on behalf of the
client and champions camh
Bill of Client Rights
• Provides guidance, support,
knowledge and skills to staff
and students in understanding,
creating and maintaining
therapeutic relationships
• Seeks supervision as needed
regarding to clinician-client
relationship issues
values, transference/countertransference
and, parallel
process issues and respond
accordingly but also intuitively
anticipates the same
• Effectively demonstrates
differential use of self in
therapeutic relationships
• Fosters, and consistently
monitors, the environment to
ensure that clients and
clinicians are safe from abuse
• Provides ongoing training and
clinical supervision to assist
and support staff in engaging
in effective therapeutic relationships
following the guidelines,
values and principles
outlined in the camh Clinical
Supervision handbook
• Provides debriefing after
critical incidents involving
clinicians and clients
• Seeks consultation with
colleagues as needed
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Clinician-Client Relationship
continued
Competent Proficient Expert
occur (e.g., own “buttons”
are pushed) and responds
appropriately seeking supervision
as necessary
• Assumes a wellness and
recovery perspective
• Creates a safe, respectful and
caring environment for clients
• Communicates with respect
• Uses language that is nonstigmatizing.
• Seeks out guidance, support,
knowledge, skills and regular
supervision with respect to
therapeutic relationships and
clinical work
regarding staff-client issues
that arise with supervisees or
with own clients
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Competent Proficient Expert
• Understands the impact of
family functioning on mental
health/illness/addictions
• Values and appropriately
includes family and social
support systems in the
assessment, planning and
treatment of client care
• Is able to assess family needs
and how best to involve them
in the client’s care
• Shares knowledge of community
supports and resources
for families with a member
experiencing mental health
and/or addiction problem(s)
• Seeks out family therapy
training and supervision
Family and Social Support • Has a comprehensive knowledge
of family systems theory,
family process, dynamics and
functioning
• Understands the impact of
illness on family functioning
and family functioning on
illness
• Conducts family assessments
using evidence-based models
• Purposefully works with client
and family to enhance family
functioning and cohesion
using evidence-based family
therapy models
• Able to provide treatment that
emphasizes family as the unit
of care
• Supervises others in family
therapy
• Recognized as an expert in
one or more models of family
therapy practice
• Provides family therapy
training and supervision
across the Centre and at
local, provincial and national
forums
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Professional Autonomy
and Accountability
Competent Proficient Expert
• Understands her or his scope
of practice, and seeks timely
assistance from proficient
and expert clinicians
• Recognizes and embraces
the importance and value of
helping relationships
• Demonstrates a commitment
to helping clients and families
achieve their goals
• Practises honesty, dignity,
respect, compassion and
integrity with each individual
and family
• Honours and maintains client
and family confidentiality
• Understands the influence of
stigma on clients and supports
clients and family who feel
stigmatized
• Maintains competency and
refrains from activities
in which he or she is not
competent
• Monitors, refines and advances
standards of practice in his or
her profession and program
• Shares knowledge and expertise
with other clinicians and
students to meet client need
• Informs competent staff
and students of resources
available to support their
practice, consolidation and
development
• Displays initiative for new
ideas within the program and
organization
• Works within program,
organization and community
to decrease stigma associated
with mental health and
addiction
• Works autonomously and
makes clinical decisions seeking
supervision appropriately
as needed
• Uses standards of practice,
legislation, ethical and legal
knowledge to clarify scope of
practice for self and others
• Anticipates factors that may
interfere with professional
autonomy of staff situation
(i.e., staffing ratios, low staff
morale) and seeks to remedy
• Shares and models dissemination
of evidence-based
practices to continuously
improve outcomes for clients
and families experiencing
mental health and / or
addiction problems
• Displays strong leadership
skills within the program,
organization and community
to influence the profession,
mental health and addiction
health care, and the provincial
health care system
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Competent Proficient Expert
• Understands, identifies and
responds to issues of diversity
and how they influence client
health and illness
• Incorporates knowledge of
cultural and socio-economic
issues and develops effective
working relationships with
various client populations
within and outside of camh
Embracing Cultural Diversity • Possesses extensive knowledge
of diversity issues and
delivers culturally sensitive
care to individuals, agencies
and communities
• Mentors colleagues in diversity
training
• Helps diverse client populations
to implement programs
in their communities
• Has comprehensive and
detailed knowledge and skill
in working with diverse populations
and applies to program
planning and evaluation
• Is a recognized expert in
diversity training and provides
consultation to specialized
populations, colleagues and
other health care professionals
who are learning to implement
culturally sensitive care
Clinical Assessment:
Interviewing, Formulation,
Treatment Planning and
Documentation
• Collaborates with clients and
other members of the health
care team to complete comprehensive
assessments that
consider mental, psychological,
social, spiritual and physical
health
• Demonstrates sensitivity to
client gender and diversity
issues
• Selects, applies and interprets
• Demonstrates a whole
systems perspective in clinical
interviewing, formulation and
documentation
• Able to independently
conduct family assessments
utilizing a systemic,
strengths-based approach
• Has acquired and applies
substantial knowledge of
clinical assessment process,
• Recognized by others as
expert in assessment
processes
• In own clinical practice and in
supervising others, is able to
take a meta-perspective on
client/family situation and
rapidly synthesize and interpret
multiple levels of data in
complex client and family
assessment situations
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Clinical Assessment:
Interviewing, Formulation,
Treatment Planning and
Documentation continued
Competent Proficient Expert
evidence-informed screening
and/or assessment tools
• Utilizes cultural assessments
tools
• Understands and utilizes evidence-based
tools appropriate
to the client’s situation (i.e.,
subscribed outcome tools in
treat, mse, dsm iv, ciwa-a
cage and physical examination
including screening for
co-morbidity)
• Understands and takes into
account social determinants
of health (i.e., poverty,
employment, housing, health,
social support, past trauma)
during the assessment
• Understands the influence of
having an addiction on mental
health and of mental health
problems on the development
of an addiction
• Considers concurrent disorders
in assessment:
measurement tools, and
evidence-based treatments
for clinical population
• Demonstrates advocacy for
clients at a higher organizational
level (e.g., odsp)
• Demonstrates knowledge of
tools for special populations
(e.g., t-ace (screening for
alcohol dependence in
pregnant women)
• Responds to issues of culture
and diversity in a purposeful
manner, building on client
strengths and seeking additional
supports and resources
as needed
• Identifies barriers within the
care delivery process that can
impact on client goals being
achieved
• Designs treatment plans for
complex, sensitive situations
that require substantial
co-ordination between services
• Applies development research
in evaluating assessment
tools and instruments to
measure clinical outcomes
• Teaches, champions and
advances innovative knowledge
in assessment practices—
interviewing, formulation,
treatment planning and camh
documentation initiatives
(e.g., electronic health record)
• Demonstrates masterful
knowledge, skill and experience
in understanding and enhancing
client motivation
• Demonstrates masterful
knowledge, skill and experience
in developing plans of care in
complex clinical situations
that honour and respect client
goals particularly when goals
of client and family differ
from those of the clinician
• Transfers knowledge and
provides supervision to
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Clinical Assessment:
Interviewing, Formulation,
Treatment Planning and
Documentation continued
Competent Proficient Expert
– able to screen for alcohol
and other drug problems,
dependence, symptoms of
withdrawal and intoxication
– able to take a history of
alcohol and drug consumption,
consequences of
alcohol and drug use
(physical and social);
assess sexual practices,
injection drug use, driving
while impaired
• Considers trauma factors
in assessment
• Ensures physical health
issues are included in
assessment
• Assesses clients’ need for
language support
• Formulates an individualized,
comprehensive plan of care
with the client to accurately
respect and reflect the complexity
of client values, preferences,
needs and goals and
• Engages with the client and
other resources to adjust the
treatment plan as needed
• Works with staff to help
bridge any gaps between
client goals and clinician
goals for client and develops
strategies to enhance client
motivation
• Coaches and/or mentors
others to ensure clinical
integrity in assessment
processes—interviewing,
formulation, treatment
planning and documentation
• Seeks supervision as needed
with respect to interviewing,
formulation and
documentation
others, ensuring clinical
integrity in clinical assessment
practices—
interviewing, formulation
and documentation
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Clinical Assessment:
Interviewing, Formulation,
Treatment Planning and
Documentation continued
Competent Proficient Expert
that integrates evidencebased
treatment modalities
• Recognizes and respects
clients’ unique differences,
strengths and barriers and
customizes individual plans
of care accordingly
• Determines and shares with
the client the treatment plan,
monitors course of treatment
and assists clients experiencing
setbacks
• Documents client assessments
in a clear, concise and
timely manner on camhapproved
forms (e.g., eIPCC)
and in accordance with camh
documentation policies and
guidelines
• Seeks assistance from experienced
staff in all aspects of
clinical assessment
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Therapeutic Interventions with
Clients, Groups and Families:
Practice, Documentation and
Case Management
Competent Proficient Expert
• Ensures that his or her practice
is grounded in theory and
applies evidence-based practices
to meet specific client
and family mental health
and/or addiction concerns
and needs
• Delivers client-, group- and
family-centred interventions
in a non-judgmental and nondiscriminatory
manner
• Tailors interventions to meet
developmental and cultural
needs of the client and family
• Understands group dynamics
and is able to effectively
facilitate group therapy,
engaging the group while
accommodating needs of
specific individuals
• Understands how to access,
and subsequently provides,
appropriate information and
resources to clients and
families to help them
• Has substantial knowledge of
and skills related to client,
group and/or family specific
interventions (e.g.,
Motivational Interviewing,
cbt, dbt, ipt, ccrt, family
therapy)
• Delivers and models above
interventions using a whole
systems perspective
• In group therapy, recognizes
difficult group dynamics and
facilitates discussion to
resolve issues while achieving
group goals
• Demonstrates an ability to
make autonomous clinical
decisions
• Applies a variety of mechanisms
to ensure excellence in
clinical care (e.g., client
satisfaction, accreditation)
• Provides mentorship to staff
with respect to clinical practice,
documentation and case
• Recognized as an expert in
providing individual, group
and/or family therapy utilizing
most effective evidence-based
approaches in a flexible,
innovative and confident
self-directed approach
• Communicates and models
excellence in client care
• Effectively facilitates group
therapy in which complex
issues arise (e.g., disruptive
behaviours, disengaged members)
and provides others in
the field with group therapy
supervision or published
materials
• Evaluates evidence-based
approaches for mental health
and/or addiction treatment
• Creates a program context
that supports quality practice
• Forms partnerships to facilitate
programs within and
outside of camh
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Therapeutic Interventions with
Clients, Groups and Families:
Practice, Documentation and
Case Management continued
Competent Proficient Expert
participate in and/or make
informed decisions about
their care and treatments
• Advocates on behalf of client;
shares knowledge of advocacy
resources available to clients
and families internally and
externally
• Supports family members
• Seeks supervision or
resources / evidence needed
to inform safe, effective clinical
practice
management issues
• Forms partnerships with
community groups
• Seeks supervision as needed
with respect to clinical practice,
documentation and case
management
• Ensures resources are available
across the organization
for staff to provide most
effective treatments for clients
• Develops opportunities for
client education and empowerment
and demonstrates
leadership in the field at local,
and national educational
events and programs
• Develops policies and practices
to meet needs of diverse
populations
• Sets standards of excellence
for client care
• Develops, modifies and
evaluates camh documentation
policies, practices and
forms to continuously
improve client and family care
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Anticipating and Responding to
Rapidly Changing Situations
Competent Proficient Expert
• Continuously assesses and
anticipates psychiatric emergencies
(e.g., self harm, harm
to others) within specified
client population using
evidence-based tools
• Recognizes symptoms and
risk of withdrawal from
alcohol and / or drugs and
responds in a timely manner
using evidence-based
protocols
• Analyzes and interprets
unusual client responses and
responds in a timely manner
• Creates and documents
safety plans
• Recognizes role in a code
white and for nursing staff,
or a code blue
• Familiar with policies and procedures
related to emergency
responses (e.g., codes blue,
white, red) and participates in
educational opportunities on
• Provides leadership, intervention
and support in all camh
emergency codes
• Supports and educates staff
and students according
emergency codes
• Modifies environment to
minimize occurrence of codes
(e.g., triggers to a code white)
• Takes leadership in developing,
modifying and evaluating
policy and practice guidelines
regarding to emergency codes
• Explicitly identifies, anticipates
and foresees an emergency
code (e.g., client appearing
aggravated and becoming
increasingly defiant) and
prevents it from occurring
with de-escalation strategies
• Provides debriefing and
supervision to staff after critical
incidents (i.e., code white,
code Blue) involving staff
and clients
• Regularly analyses code
functioning with team
• Invites external perspectives
on risk assessment and
mitigating strategies
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Anticipating and Responding to
Rapidly Changing Situations
continued
Competent Proficient Expert
these codes
• Demonstrates ability to intervene
appropriately with
clients assessed to be at risk
of harm to self or others
• Seeks immediate assistance
in rapidly changing situations
that exceed level of competence
or confidence
Program Development,
Implementation and Evaluation
of Care
Competent
• Recognizes, respects and
validates client and family
goals in the development,
implementation and evaluation
of camh approaches
to care
and programs
• Identifies need for refining
current approaches to care
and/or for developing new
approaches or programs
of care
Proficient
• Demonstrates global perspective
on developing, implementing
and evaluating client
care programs
• Leads team and supervises
others in generating ideas for
new programs or modifying
existing ones, and in implementing
and evaluating
programs
• Collaborates effectively with
colleagues involved in the
• Leads team in program development,
implementation and
evaluation across programs,
camh as an organization
and within the community
• Acts as leader for camh in
addressing gaps for specialized
populations at local,
provincial or national level
and incorporates findings
into ongoing program
development
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Program Development,
Implementation and Evaluation
of Care continued
Competent Proficient Expert
• Plans and implements new
programs and utilizes analytical
skills to evaluate them
• Evaluates outcomes of treatment
in light of client and
health care team goals and
modifies plans with client and
team accordingly
• Contributes to reports related
to modifying or designing
new approaches or programs
program development and
evaluation
• Applies knowledge of
research methodologies in
analysing data
• Independently writes reports
related to program changes,
development of new programs
and evaluation of programs
• Is a recognized expert
and leader in program
development, planning
and evaluation
Outreach
• Demonstrates good understanding
of outreach needs
in a community within
specialized population
• Participates in program delivery
and evaluation of culturally
sensitive outreach programs
based on evidence-based
practices
• Seeks out necessary supervision
in delivering and
evaluating outreach programs
• Delivers a variety of evidencebased
outreach services in
the community
• Supports and supervises
others to design and deliver
culturally sensitive outreach
services
• Is a recognized expert for
designing outreach programs
for specialized populations
• Identifies gaps in outreach
programs and collaborates
with community partners to
improve and modify existing
programs or create new ones
• Provides supervision and
leadership across camh and
supports programs to be
delivered within communities
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Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Team Work, Collaboration and
Partnerships
Competent Proficient Expert
• Demonstrates knowledge of
the roles of various members
of the team
• Displays initiative, works collaboratively
within the team,
asks questions, exercises
professional judgment and
seeks consultation as needed
• Recognizes potential for conflict
and applies basic conflict
resolution strategies
• Possesses knowledge and
skill in professional communication,
leadership and
negotiation strategies
• Works positively within team
to effectively transform situations
of conflict into healthier
interpersonal interactions
• Demonstrates good understanding
of team and group
dynamics
• Embraces and behaves in
accordance with camh values
and strategic direction
136
• Possesses excellent understanding
and demonstrates
skill related to effective team
dynamics and functioning
• Successfully assists staff to
manage conflicts that arise
within the team
• Shares information directly
and openly and will engage in
difficult conversations
• Builds teams that work well
together, experience trust,
openness and flexibility
• Creates team context that
effectively addresses conflict
and ambiguity
• Works with team differences
to develop a stronger, more
effective team
• Addresses power dynamics
• Creates a team culture that
facilitates collaboration on
multiple dimensions within
multiple systems to improve
client care
• Teaches, coaches and mentors
staff and draws forth their
strengths
• Offers supervision that is consistent
with qualities of a
supervisor-supervisee relationship
as outlined in the camh
Clinical Supervision Handbook
• Creates opportunities to
develop clinicians into leaders
• Possesses community development
skills and pursues
partnerships with other internal
and external providers
• Fosters innovation, creativity
and commitment to organizational
change
• Builds partnerships with
various levels of government
to champion the agenda of
camh

Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Ethical, Organizational and
Legal Accountabilities
Competent Proficient Expert
• Identifies and understands
ethical concerns, issues and
dilemmas as they pertain to
the client-clinician relationship
and to the larger field of
mental health and addictions
• Demonstrates knowledge of
the implications of ethical issues
in interactions with clients
experiencing mental health
and/or addiction problems
• Collects and uses available
resources from various
sources to resolve ethical
issues
• Has a good working knowledge
of ethics and is able to
make ethical decisions
• Is knowledgeable about camh
values, policies, procedures,
program specific initiatives
and strategic directions
• Demonstrates awareness
of relevant legislation that
guides practice
• Advocates for the best possible
care for clients, for her or
his profession and for the
health care system
• Engages self and staff in critical
thinking about identifying and
resolving ethical issues,
concerns and dilemmas
• Works with camh partners to
ensure compliance to standards
of professional, ethical
practice
• Creates manageable staff
workload and scheduling for
staff giving them sufficient
time to discuss and plan care
with colleagues
• Leads accreditation and quality
improvement initiatives at
program level
• Represents program and / or
camh in internal / external
committees
• Has a strong working knowledge
of legislation in caring
• Recognized as an expert in
ethics in the field of mental
health and addiction
• Collaborates with other health
care professionals to challenge
and co-ordinate institutional
resources to achieve the most
effective outcomes
• Creates environments within
camh and with external partners
that promote safe, ethical,
legal, professional practice
and deals effectively with staff
and/or clients when ethical
issues arise
• Leads accreditation and quality
improvement initiatives at
organizational level and in
collaboration with camh
external partners
• Represents camh externally
(e.g., committees, media,
community development
projects) as a leader in a
137

Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Ethical, Organizational and
Legal Accountabilities continued
Competent Proficient Expert
• Ensures client safety and
protects the client from abuse;
reports unsafe practices
• Organizes workload and
develops time management
skills to meet responsibilities
• Integrates quality improvement
initiatives into practice
• Completes all required workload
measurements in a timely,
professional manner
• Completes documentation
in accordance with camh
standards
• Displays commitment to
continuous quality improvement
(i.e., cqi, InfoMed)
• Participates in program and
camh internal/external
committees
for clients and families in his
or her specialized mental
health and / or addictions
field
specialized field of mental
health and / or addiction
practice and / or research
138

Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Professional Development and
Research
Competent Proficient Expert
• Identifies opportunities for
continued professional development
that correspond with
personal career goals
• Seeks out and receives clinical
supervision on a regular basis
consistent with the value of
lifelong learning
• Engages in reflective practice
and completes annual selfevaluation
(padr) with
Program Manager and / or
Program apn/apc/discipline
Chief
• Utilizes research and identifies
research opportunities
• Assumes responsibility for
monitoring her or his own
needs with respect to professional
development and seeks
out supervision and consultation
as needed
• Provides competent staff and
students with feedback that
encourages professional
growth
• Demonstrates mastery in
evaluation of practice, utilization
and dissemination of
research
• Engages in research by
critiquing research reports
• Takes leadership role in
clinical research activities
(e.g., literature searches,
subject recruitment, pre /
post testing, report writing)
• Conducts internal and external
presentations of clinical
work and / or research
• Independently monitors and
evaluates his or her own practice,
professional development
needs and goals, and need for
clinical consultation/supervison
• Develops, facilitates and
implements learning activities
to promote professional
development of all interdisciplinary
staff members
• Provides constructive feedback
and recognition of
accomplishments to staff
• Critically analyses program
practice and makes recommendations
at program and
senior administration level for
improvement
• Leads team in evaluation of
practice through research and
application of current outcome
measures and development
of population-specific ones
• Actively develops proposals
for funding
139

Clinical Supervision Handbook Core Clinical Practice Competencies
DOMAIN OF PRACITCE LEVELS OF PRACTICE
Professional Development and
Research continued
Competent Proficient Expert
• Participates in the ethical
review of research ensuring
that ethical guidelines are
followed to protect research
participants and investigators
• Publishes papers in clinical
and / or research journals
and books
Consultation and Education • Provides supervision of new
• Acts as a
preceptor/mentor/supervisor
for students and new staff to
support professional growth
• Respects and solicits interdisciplinary
input into client and
family care
140
camh staff, undergraduates
and students from community
colleges
• May provide teaching and / or
training to community partners
and / or universities
• Acts as primary supervisor for
Masters and PhD students
and staff
• Creates a context for staff to
be offered supervision in a
safe, respectful, non-judgmental
manner (as •outlined
in the camh Clinical
Supervision Handbook) as a
means of improving clinical
practice andclient outcomes
• Provides supervision of supervision
to clinical colleagues
• May provide teaching and / or
training to community partners
universities

A Pan American Health Organization /
World Health Organization Collaborating Centre
3542/03-2008 PG121