Clinical Supervision Is Being Offered and Evaluated to Address These Two Major Problems
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Literature Review of Supervision and Leadership in Helping Professions
Introduction his literature review examines best practices and emerging models of supervision used in high-stakes, high-stress jobs, specifically in the public arena and with helping Tprofessionals like nurses, paramedics, and police officers. A side-by-side comparison is also included of the models discussed.
Nurses The field of nursing has recently moved into the use clinical supervision to improve job satisfaction and quality of patient care. In such a high-stakes profession, quality of services provided is of the utmost importance. Some studies have indicated that one-third to two-thirds of nurses change jobs or leave the profession in their first year of employment (Mills et al., 2005). Quality of patient care is often adversely affected by high rates of professional turnover in nursing, and the use of clinical supervision is being offered and evaluated to address these two major problems. The term “clinical supervision” is used to mean different things across different disciplines. Within nursing, Mills and colleagues describe the characteristics of clinical supervision as “provision of professional support and guidance and advancement of clinical practice through reflection” (Mills et al., 2005). Clinical supervisory relationships are similar to mentoring, as they are both reliant on the development of a strong sense of reciprocity and accountability and occur over a long period of time. However, clinical supervisory sessions differ from mentoring in that they are generally facilitated in small groups and preferably away from the work setting (Mills et al., 2005). Others expand on this definition by emphasizing clinical supervision as a process that builds the reflective and clinical capacities of nurses, in contrast with traditional supervision that relates to the delegation of tasks, oversight of work, and provision of direct guidance (White and Roche, 2006). Clinical supervision is used in addition to, not in place of, these other traditional forms of supervision.
[1] Clinical supervision can use reflection to analyze ethics in the work by asking three questions: Is it safe: Is it right? Is it kind? (Tony et al, 2008). In order for clinical supervision to have an effect, no prescriptive amount of time (neither length nor frequency) has been discovered to make it effective, but literature points to the need for regularity of clinical supervision—at least once/month for 45 minutes or an hour—consistent over time for effect to be seen (Tony et al, 2008). Promising research indicates that clinical supervision in nursing can increase quality of patient care Clinical supervision sessions are and nurses’ feeling of wellbeing (Mills et al., 2005). generally facilitated in small Research also indicated that clinical supervision is groups, preferably away from restorative, and helps nurses deal with stressful situations work; build the reflective and like patient death; some research indicates a relationship between clinical supervision and improved problem solving clinical capacities of nurses; are in nurses; other studies have tied clinical supervision to used in addition to other decreased sick days and increase in numbers of patients traditional forms of supervision; treated per nurse (Tony et al, 2008). and, research reveals, can The characteristics of clinical supervision vary and improve quality of patient care can affect outcomes, so researchers have developed and and nurses’ feeling of wellbeing used the Manchester Clinical Supervision Scale (MCSS) to quantitatively measure satisfaction with and effectiveness and problem solving. of clinical supervision (see Resources). This scale has been used across 12 countries; in one study, the use of MCSS showed clinical supervision of nurses was perceived as more effective by nurses when they chose their own supervisor and when the supervision occurred at least once a month for at least an hour (Cummins, 2008). Several studies found resistance of nurses to engage in clinical supervision (Cummins, 2008). Authors emphasize that support and buy-in from leadership is necessary to develop and maintain programs of clinical supervision. These programs were often discontinued by hospitals, even with positive results, after studies ended (Tony et al, 2008).
Paramedics In supervision of paramedics, some entities have begun employing non-traditional supervision models such as group supervision and use of trained peer supports. Paramedics, or emergency medical technicians (EMT), face challenges of working in isolation in the field in high-stress, crisis situations. The use of the above-mentioned models addresses these unique characteristics of the work of EMTs and may overlap with some of the challenges faced by child welfare workers. Paramedics are susceptible to burnout, post-traumatic stress disorder, and other work- related stressors and mental health problems (Brink, Bäck-Pettersson & Sernert, 2012). Brink and colleagues looked at use of group supervision with ambulance care personnel in Sweden to help mitigate these stressors. Group supervision was found to positively affect the paramedics’ personal and professional development. It also seemed to help new staff develop competence more quickly. Researchers attributed this in part to the wisdom new professionals were able to get from consulting with more seasoned paramedics in the group supervision format (Brink, Bäck-Pettersson& Sernert, 2012).
[2] This model followed a prescribed format of group supervision in which the group decided on one issue to address from a member of the group, the member presented, the group gave feedback, and the member who had initially presented then summed up the discussion. This aligns with a model developed by Pertoft and Larsen (2003). In evaluation, participants shared that this model created security and invited participation. The researchers believe implementation of this model could help prevent burnout in this profession, as well as facilitate transfer of knowledge and skill from Group supervision was found to more experienced to less experienced professionals. Group positively affect the paramedics’ supervision is seen as a favorable model in the field of personal and professional paramedics, and perhaps child welfare, because of the development; help new staff collegial, team-oriented culture of the profession (Brink, develop competence more Bäck-Pettersson& Sernert, 2012). Another international, non-traditional model of supervision quickly; and create security and and employee support may have implications for child invite participation; and welfare. Scully (2011) outlines research based on 18 years according to research, it could of implementation in Australia of the use of specially help prevent burnout and trained “Peer Support Officers” (PSO) to support fellow facilitate transfer of knowledge paramedics especially after they have experienced a and skill. potentially traumatic event. Unlike other forms of supervision, the PSO support is not given on a regularly scheduled basis, but depends on the needs of the individual. Supervision of the PSO, however, is regularly mandated and includes twice yearly supervision with a mental health professional as well as monthly group supervision. PSOs are also specially selected and trained in topics like counseling and communication. This model makes use of the aforementioned collegiality in the field, like the group supervision model, with use of co-worker support in order to buffer stress. Advantageously, PSO are known to fellow staff, as they often live and work in the same area. Additionally, the PSO program is not a stand-alone supervision model, just like clinical supervision of nurses is not a stand-alone. Rather, PSO are one of many supports offered to the staff. Outcomes of the PSO model are promising. The use of PSOs was correlated with significant decreases in incidence of PTSD in staff (Scully, 2011).
Police Police officers, like nurses, paramedics, and child welfare workers, face an array of on- the-job challenges related to the high-stress, high-impact nature of police work. In light of these specialized needs, researchers and practitioners have looked at the specifics skills and styles needed for police supervision to be effective. Engel (2002) looked at police officers’ time spent on different tasks related to their supervisors’ style of supervision and found that supervision style had a significant effect on how officers spent their time. Supervision styles were grouped in four categories based on previous research; the study focused on the “innovative” and “active” types. Officers with “active” supervisors spent more time on self-initiated community policing activities, whereas officers with “innovative” supervisors spent more time on administrative activities (see appendix for descriptions of the four styles of supervision). Findings showed that supervision style did seem to influence officer behavior. “Active” supervisors—those who led by example—had the strongest influence on supervisee behavior. It was also found that this influence could be positive
[3] or negative, depending on the supervisor: “Leading by example is only an effective supervisory tool if supervisors are engaging in activities that support the legitimate goals of their departments” (Engel 2002). Other scholars have looked at how police supervisor training focuses on supporting skill development in Research found that supervision transition/promotion from line officer to supervisor. This style had a significant effect on how perspective is based in the idea that managerial skills are police officers spent their time. learned and that just because an officer is a successful line Officers with “active” supervisors officer does not mean he/she has already developed the skills needed to be a successful supervisor. More and Miller spent more time on self-initiated (2014) explain the Hu-TACK model for supervisor community policing activities; training, used across many law enforcement agencies. Hu- officers with “innovative” TACK in an acronym for the supervisory skills needed: supervisors spent more time on Human Skills, Tactical Skills, Affective Skills, Conceptual administrative activities. “Active” Skills, Knowledge-based skills (see appendix descriptions supervisors—those who led by of each skill). Hu-TACK is a supervisory philosophy, which draws on literature from the army and other branches example—had the strongest of the military. Hu-TACK outlines the skill areas that influence on supervisee behavior, supervisors must develop, but is not a curriculum and does but this could be positive or not provide details of how these skills are taught or learned; negative, depending on the nor does it offer clear structures for evaluation. As such, supervisor. research on implementation or effectiveness of this philosophy is not available (More & Miller, 2014).
Conclusion Themes Across Helping Professions cross these helping professions, themes arise indicating that specialized, discipline- specific supervision and support are necessary for staff in these fields. However, as Ademonstrated by the varying models discussed above, there is not a one-size-fits-all approach, and many borrow from allied fields in developing their supervision and support models. Relatedly, child welfare supervision models may benefit from incorporating aspects of models developed in allied fields, including some of the international models mentioned. For reference, the diagram below outlines some of the main characteristics of the supervision and support structures discussed.
Discipline Supervision Basic characteristics Evaluation Model
Nurses Clinical - Professional advancement and skill Research indicates it may: supervision development through supported reflection; - Increase quality of patient - Reliant on reciprocity and care; accountability in supervisory - Improve nurses’ feeling of relationship; wellbeing; - Best when occurs regularly over a - Help nurses deal with
[4] long period of time; stressful situations like - In contrast with traditional patient death; supervision which relates to the - Improve problem solving delegation of tasks, oversight of in nurses; work, and provision of direct - Lead to decreased sick guidance; days and increase in - Used in addition to, not in place of, numbers of patients these other traditional forms of treated per nurse. supervision. Paramedics Group - Group meets regularly; - Group supervision was supervision - Follows prescribed format in which found to positively affect they decide on one issue to address the paramedics’ personal from a member of the group, the and professional member presents, the group gives development; feedback, and the member who had - May help new staff initially presented then sums up the develop competence more discussion (aligns with a model quickly. developed by Pertoft and Larsen, 2003). Peer Support - Provision of PSO support depends The use of PSOs was Officers on the needs of the individual; correlated with significant - Not a stand-alone supervision decreases in incidence of model, rather one of many supports; PTSD in staff. - PSO are specially selected and trained in topics like counseling and communication; - PSO receive twice yearly supervision with a mental health professional and monthly group supervision; - PSO are known to fellow staff, as the often live and work in the same area. Police Four - Four supervision styles were - Supervision style had a supervision identified in research: traditional, significant effect on how styles innovative, supportive, and active officers spent their time; (see resources for description). - Officers with “active” supervisors spent more time on self-initiated community policing activities, whereas officers with “innovative” supervisors spent more time on administrative activities.
[5] Hu-TACK - Hu-TACK in an acronym for the - Outlines the skill areas supervisory skills needed: Human that supervisors must Skills, Tactical Skills, Affective develop; Skills, Conceptual Skills, - Not a curriculum and Knowledge-based skills (see does not provide details Resources for descriptions of each of how these skills are skill); taught/learned nor clear - Based on idea that managerial skills structures for evaluation; are learned; - Research on - Supervisory philosophy, draws on implementation or literature from branches of the effectiveness of this military. philosophy is not available.
Resources Four styles of police supervision. From Engel, R. S. (2002). Patrol officer supervision in the community policing era. Journal of Criminal Justice, 30(1), 51-64.
‘‘Traditional’’ supervisors expect aggressive enforcement from subordinates and do not expect community-oriented activity. These supervisors are highly task-oriented (expect subordinates to produce measurable outcomes and also emphasize paperwork and documentation) and are decision makers. These supervisors give more instruction to subordinates and are more likely to take over a situation or handle it themselves. Finally, these supervisors are less likely to reward and more likely to punish subordinates. The ultimate concern for traditional supervisors is to control subordinate behavior. ‘‘Innovative’’ supervisors expect community-oriented activity from their subordinates. They are strongly relation-oriented and are not task-oriented (that is, they do not expect production of measurable output). Innovative supervisors have more perceived power in the organization and have positive views of subordinates. They are more receptive to innovative policies and changes in the organization. The ultimate goal for these supervisors is to develop the problem-solving skills of subordinates. This is typically done through mentoring and coaching subordinates. ‘‘Supportive’’ supervisors are also highly relationally oriented; however, they show concern for subordinates by protecting them from unfair criticism and punishment. These supervisors provide a buffer between subordinates and management. They have high levels of inspirational motivation, emphasize teamwork, and encourage creativity by supporting subordinates. They are also more likely than other types of supervisors to reward subordinates. Supportive supervisors are not task oriented; that is, they are not concerned with work output measures. The ultimate goal for supportive supervisors is to develop subordinates; however, this is accomplished through providing protection and being an advocate. Unlike innovative supervisors, supportive supervisors see management as something officers need to be protected from. ‘‘Active’’ supervisors are characterized by their high levels of activity in the field. This activity includes both patrol work and supervisory functions. These supervisors tend to be decision- makers, taking over and handling situations themselves. Unlike traditional supervisors, these
[6] supervisors feel they have power within the organization and have positive views of subordinates. Active supervisors also have lower levels of inspirational motivation. The ultimate goal for active supervisors is to be active field supervisors, performing the dual function of street officer and supervisor.
Sampling of Hu-TACK supervisor skills. Adapted from More & Miller (2014).
Human Tactical Affective Conceptual Knowledge
Coaches officers Develops the Accepts Assesses Fairly technical responsibility performance implements expertise tailored departmental to the problem policies, rules, regulations
Counsels Establishes a Creates an Demonstrates the Is capable of employees system of control environment ability to use doing all tasks an based on belief data officer must in equality perform
Deals with each Establishes Deals fairly with Enhances and Knows each officer as an operational subordinates improves officer’s individual priorities proficiency workload
Develops a Implements Integration of Identifies Reviews officers’ rapport with procedures in organizational emerging reports for officers conformance and community problems and accuracy, with value systems works for their thoroughness, departmental resolution and quality policy
Gives praise Ensures that Performs as a Makes decisions Trains and when appropriate every officer is role model develops officers aware of task and is oriented to its attainment
[7] References Brink, P., Bäck-Pettersson, S., & Sernert, N. (2012). Group supervision as a means of developing professional competence within pre-hospital care. International emergency nursing, 20(2), 76-82. Cummins, A. (2009). Clinical supervision: The way forward? A review of the literature. Nurse education in practice, 9(3), 215-220. Davys, A., & Beddoe, L. (2010). Best practice in professional supervision: A guide for the helping professions. Jessica Kingsley Publishers. Engel, R. S. (2002). Patrol officer supervision in the community policing era. Journal of Criminal Justice, 30(1), 51-64. More, H. W., & Miller, L. S. (2014). Effective police supervision. Routledge. Scully, P. J. (2011). Taking care of staff: A comprehensive model of support for paramedics and emergency medical dispatchers. Traumatology, 17(4), 35. Tony, B., Louise, B., Christine, J., & Majda, P. (2008). Wicked spell or magic bullet? A review of the clinical supervision literature 2001–2007. Nurse Education Today, 28(3), 264-272. White, E., & Roche, M. (2006). A selective review of mental health nursing in New South Wales, Australia, in relation to clinical supervision. International Journal of Mental Health Nursing, 15(3), 209-219.
Mills, J. E., Francis, K. L., & Bonner, A. (2005). Mentoring, clinical supervision and preceptoring: clarifying the conceptual definitions for Australian rural nurses. A review of the literature. Rural and Remote Health, 5(3), 410.
Pertoft, M., & Larsen, B. (2003). Group supervision for professionals in treatment units. Stockholm: Liber AB.
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