Competences for Clinical Supervision in Psychiatric/Mental Health Nursing
10.5 Discussion and Implications
emotional literacy and draw particular attention to the need to have self-awareness and thus the skills, knowledge and attitudes associated with perpetual growth in awareness. Significant sections of Bond and Holland’s (1998) book are dedicated to specific interpersonal skills and cite the seminal work of Heron (1990).
Heron’s framework has been adopted as a supervision framework in nursing (see, e.g. Chambers and Long 1995; Cutcliffe and Epling 1997; Driscoll 2000;
Fowler 1996; Johns and Butcher 1993). The six-category system describes six basic kinds of intention a supervisor can have when working with a supervisee. Prescriptive interventions seek to influence and direct the behaviour of the supervisee and include offering advice and making suggestions. To be informative is to offer infor- mation or instruction. Confronting interventions directly challenge the rigid and maladaptive ways that limit the supervisee. A confronting intervention tells an uncomfortable truth ‘but does so with love, in order that the client concerned may see it and fully acknowledge it’ (Heron 1989, p. 45). Cathartic interventions assist the client to abreact painful emotion, for example, grief, fear and anger. Catalytic interventions include encouraging further self-exploration, self-directed living, learning and problem solving in the client. Lastly, to be supportive is to validate or confirm the worth of the client’s person, qualities, attitudes or actions.
disciplines or specific domains of practice. See, for example, Roth and Pilling’s (2008) competency framework developed for the supervision of psychological ther- apies which was commissioned by the Care Services Improvement Partnership (CSIP), Skills for Health and NHS Education for Scotland (NES) and the Scottish Government (NES and Scottish Government 2008). The generic supervision com- petences were developed following a comprehensive review of the psychological therapies’ supervision literature in addition to those books and papers viewed as authoritative by professional groups (Roth and Pilling 2008).
Our review also found noticeable overlap and/or repetition of (and/or very closely conceptually related) certain knowledge, attitudes and skills across different authors. By way of an example, several authors made specific reference to knowl- edge, attitudes and skills related to or concerning the purpose of CS and how this varies according to specific theories/models/approaches. In one such case, broad generic competencies (e.g. ‘knowledge of and about the purpose(s) of CS’) seems to have a high degree of congruence with introductory-level courses as there is only time/space to offer overviews rather than in-depth, detailed material. Perhaps a more detailed version of the same competencies is the example, ‘Knowledge about the management, educative and supportive functions/practices of CS’, and this lends itself to a longer, more intensive course/training/preparation. More detailed still and ergo, more fitting with even more intensive, detailed and comprehensive training/courses/preparation is the competency ‘Knowledge of: the importance of structure in CS, theoretical models, formats, the underpinning philosophy and pur- pose of CS (and what it is not!), stages of relationship formation, and how to form therapeutic working alliances’. Accordingly, the authors wish to advance that there are core or basic (entry level?) competencies in CS and at least (probably more) one other ‘advanced, specialist’ level of competencies. This is hardly surprising given the different levels of degree of training/education in CS and given this corollary with other interpersonally focused health-orientated disciplinary competencies.
Discussion Point 2 The competencies being advanced for radically different degrees in (or of) clinical supervisor (and supervisee) training/preparation.
The findings from our review and related writings found in a recent CS publication illustrate how there is no apparent consensus in the literature as to what is required to prepare practitioners (adequately) to become supervisors (or supervisees). Currently the preparation of supervisors/supervisees for their role(s) within CS varies from no preparation at all (Milne 2009) to in-depth postgraduate-level studies (Sloan and Fleming 2011). While not wishing necessarily to homogenise preparation in/for CS, evidently, this wide variation also tolerates, if not actually encourages, similar varia- tion in curricula (course) content and corresponding differences in emphasis vis-à-vis competency acquisition. Intuitively, it seems logical that there is a relationship between the quality of the CS preparation experience, the focus within the said curri- cula on competencies and the resultant efficacy of CS subsequently offered by the practitioner. On a related note, in addition to the well-versed argument regarding improvements in CS resulting from experiential learning (e.g. experiential learning as one means to acquire and refine competencies), it seems likely that very short CS
preparation courses (with little or no attention to competency acquisition) are very unlikely to produce well-prepared, highly effective supervisors. While the authors acknowledge that this is a somewhat simplistic proposition and the efficacy of the preparation will clearly be influenced by a range of variables, there exists some evi- dence that supports this proposition (Butterworth et al. 1997).
Now this is not to suggest that there is no utility or value in 1 day workshops on CS. The authors are aware that such educational experience can ‘whet the appetite’
for more, can provide a brief though interesting glimpse into the world of CS, and can help dispel some of the more common miscomprehensions and misunderstand- ings. Yet we would argue, and the limited evidence would appear to support our view, that such 1-day workshops are not sufficient to expose would-be supervisors to the wide range of (possibly) required competencies, let alone provide sufficient time and ‘space’ for competency practice and refinement.
Perhaps what is necessary is a range of CS preparatory ‘courses’ of different sizes, lengths and intensities, aimed at different groups and with different emphasis on competencies. Drawing on Bloom et al.’s1 work once more, he described so- called ‘higher-level’ thinking skills and, importantly, such higher-level thinking skills require prior learning (acquisition) of basic skills, which, according to Bloom, are then integrated into higher-order skills. Further, Bloom declared that skills at different levels must be taught (and evaluated) in different ways. Such central tenets then indicate that CS course designers and instructors need to take these differences into account when considering how competencies are to be covered, acquired and refined in preparatory courses. As a result, if one accepts the cogency of Bloom’s position and applies these tenets to CS courses/preparation and training, then there is a strong pedagogical case for having a range of different CS ‘courses’, some focused on ‘basic competencies and others on ‘higher level CS competencies’.
There are additional pedagogical lessons and rationales to support the argument for having a range of ‘courses’ when one considers related (specialist) clinical prac- tices and the different courses available to practitioners. To draw on the example of courses for (in) cognitive behavioural therapy, introductory ‘in-house’ overviews and study days, short courses and full-time masters’ level courses at university are available. While no doubt each deserving of merit, and each serving a particular purpose, the authors sincerely doubt that the recipient of an in-house study day or short course would claim to be proficient2 as a cognitive behavioural therapist.
The authors are also mindful, particularly in the post-2009 international economic
‘meltdown’, that any consideration of providing education/training in/for CS will inevitably have to be cognizant of the costs. Interestingly, the costs associated with providing adequate and appropriate training/education in CS were mentioned with conspicuous regularity during the 1990s (see, e.g. Smith 1995). However, the authors would caution against possible shortcuts in CS preparation, expecting disproportionate outcomes and competency acquisition/refinement to financial support and course length. Furthermore, the authors wish to advance the argument
1 And the many fine scholarly works that this original work spawned.
2 And the authors would argue—safe.
that it is a false economy to ‘shortcut’ on CS preparation when there is evidence, albeit limited in scope, size and validity, that shows how receiving high-quality CS can have a positive contribution to well-being (e.g. recipients of CS have lower burnout scores, depersonalisation scores, lower sickness (absence) rates, etc.).3 Organisations there- fore need to be thoughtful about allocating their limited training budgets to CS prepa- ration, perhaps designing strategic plans to provide different courses to different practitioners. That is, while in an ideal world it may be advantageous to provide inten- sive CS preparation that fully equips supervisors with all the competencies, this is likely to be cost prohibitive, and thus offering a combination of courses to ‘train the trainers’ and introductory workshops might be a more realistic proposition.
Discussion Point 3 CS education/training must include attention to the acquisition and/or development or required qualities in addition to skills and knowledge.
Competency-based education (and training) is now fairly commonplace in nursing, clinical psychology and counselling/psychotherapy programmes (Arema and McCoy 2010; Catano et al. 2007; Manring et al. 2003; Mulholland 1994). Given the not insub- stantial conceptual and practice overlap between CS and the above-listed disciplines, it is perhaps not surprising that a competency-based approach to education and train- ing in CS is starting to emerge (see, e.g. Bagnall et al. 2011; Roth and Pilling 2008).
While competency-based education cannot claim to be a unified or homogenised edu- cational approach given the variety of extant conceptualisations in the literature (see, e.g. Arema and McCoy 2010), there is some agreement that the characteristics of competency-based learning include acquisition of essential cognitive, psychomotor and affective skills (Arema and McCoy 2010). The authors of this paper advance the view that some affective skills are clearly related to qualities in the individual. The etymological origins of the word competent shed further light on the conceptual simi- larity of affective skills and qualities as the original Latin word ‘competent’ means having essential qualities and abilities to function in specific ways.
In addition, our review of the extant literature revealed a range of qualities that have been posited as competencies necessary for effective, comprehensive, compas- sionate and robust CS practice (see Tables 10.1 and 10.3) Accordingly, CS compe- tency training/education must include attention to fostering and developing appropriate qualities in the supervisor. In the absence of this attention, aspirant supervisors acquire only relevant knowledge and particular skills. This has the potential to create CS encounters and interactions that, while maybe technically competent, are devoid of the required, underpinning qualities/attitudes.
By way of an example, demonstrating and communicating an empathic ‘felt sense’ of the supervisees’ difficulty(ies) is often posited as an important element of supervision (see, e.g. Sloan 2006). The literature, both that of a recognised vintage and more contemporary, is clear in pointing out how individuals have different innate levels of empathy or ‘empathic maturity’ (Carkhuff and Traux 1965; Connor 1994; Cutcliffe and Cassedy 1998; Olsen 2001; Rogers 1975). Further, while equip- ping supervisors with the technical skills to communicate empathy is an appropriate
3 Please see Cutcliffe et al. (2011) for a comprehensive review of this evidence.
competency to include, focusing only on skills and knowledge can create a situation where supervisors are able to communicate a feeling (empathy) that they are not necessarily feeling; the skills have no grounding in attitude/quality (Cutcliffe and Cassedy 1998). Bearing in mind the documented need for genuineness or realness in CS (interestingly, another quality) and how such a quality is compromised when practitioners do not possess the affective component or sensitivities that need to underpin the technical skill, the case for ensuring CS education/training incorpo- rates the development of certain required qualities becomes clear.
Conclusion
It is noteworthy that nursing has been remised in establishing a suitable and pro- fessionally relevant competency framework for CS in nursing. Arguably the absence of a competency framework with explicit knowledge, attitudes and skills fundamental to the engagement in effective CS has had some contribution to the less than satisfactory outcomes relating to CS in previous research. The authors hope that this paper stimulates debate on the fundamental intention of CS for nursing, and in particular, the guidance a competency framework would offer those engaged in CS (clinical supervisors and supervisees), those providing edu- cational preparation for its participants and to some extent, what process vari- ables evaluators/researchers could measure when investigating outcomes derived from CS. Following on from this, nursing may be able to establish accreditation criteria for clinical supervisors.
Box 10.1 Recommended Reading on Clinical Supervision
Cutcliffe, J.R., Butterworth, T. and Proctor, B. (Eds.) (2001) Fundamental Themes in Clinical Supervision, Routledge, London.
(Foreword by Sarah Mullally, Chief Nursing Officer for the UK).
Cutcliffe, J. R., Hyrkas, K., Fowler, J. (2011) Routledge Handbook of Clinical Supervision: Fundamental International Themes. Routledge, London.
Hanlon, P., Sloan, G. (2011) Make room for clinical supervision: using an educational DVD resource. British Journal of Well Being. 2(3), pp. 27–31.
Lavalette, H., Alexander, J., Gilmour, C., Allan, J., Sloan, G. (2011) Separating clinical and line management supervision in occupational therapy.
British Journal of Well Being. 2(6), pp. 18–21.
Sloan (1999) Good characteristics of a clinical supervisor: a community mental health nurse perspective Journal of Advanced Nursing 30(3), 713–722.
Sloan and Fleming (2011) A literature review of clinical supervision in nursing in the UK. IN: Routledge Handbook of Clinical Supervision: Global Perspectives on Fundamental Themes—2nd Edition of Fundamental Themes of Clinical Supervision. Routledge, London.
Sloan and Fleming (2011) Training requirement for clinical supervision in the UK. IN: Routledge Handbook of Clinical Supervision: Global Perspectives on Fundamental Themes—2nd Edition of Fundamental Themes of Clinical Supervision. Routledge, London.
Sloan (2006) Clinical Supervision in Mental Health Nursing. Wiley &
Sons, London.
Acknowledgments This chapter has been reproduced, with kind permission from the publisher.
Taylor Francis, from the journal article referenced: Cutcliffe, J.R., & Sloan, G (2014) Towards a consensus of a competency framework for Clinical Supervision in nursing: knowledge, attitudes and skills. The Clinical Supervisor, 33(2), 182–203.
References
Abel-Smith B (1960) A history of the nursing profession. Heinemann, London
Anema M, McCoy J (2010) Competency based nursing education: guide to achieving outstanding learner outcomes. Springer, New York
Arvidsson B, Fridlund B (2005) Factors influencing nurse supervisor competence: a critical inci- dent analysis study. J Nurs Manag 13:231–237
Bagnall G, Sloan G, Platz S, Murphy S (2011) NHS education for Scotland training in generic supervision competencies for psychological therapies: pilot course development and evalua- tion. Ment Health Pract 14(6):18–23
Bakarman AA (2004) Attitude, skill, and knowledge: (ASK) a new model for design education (recovered 2012) http://faculty.ksu.edu.sa/10177/Documents/ASK%20Final%20paper.pdf Bartle J (2000) Clinical supervision: its place within the quality agenda. Nurs Manag 7(5):30–33 Benfer BA (1979) Clinical supervision as a support system for the care-giver. Perspect Psychiatr
Care 17(1):13–17
Bloom B, Englehart M, Furst E, Hill W, Krathwohl D (1956) Taxonomy of educational objec- tives: the classification of educational goals. Handbook I: cognitive domain. Longmans, Green, New York
Bond M, Holland S (1998) Skills of clinical supervision: a practical guide for supervisees, clinical supervisors and managers. Open University Press, Buckingham
Burns ME (1958) The historical development of the process of casework supervision as seen in the professional literature of social work. Department of Social Work University of Chicago, Chicago
Butterworth T, Carson J, White E, Jeacock J, Clements A, Bishop V (1997) It is good to talk: an evaluation study in England and Scotland. University of Manchester, Manchester
Buus N, Gonge H (2009) Empirical studies of clinical supervision in psychiatric nursing: a sys- tematic literature review and methodological critique. Int J Ment Health Nurs 18(4):250–264 Carkhuff R, Traux C (1965) Training in counselling and psychotherapy: an evaluation of an inte-
grated didactic and experiential approach. J Couns Psychol 29:333–336
Catano V, Darr M, Campbell C (2007) Performance appraisal of behaviour-based competencies: a reliable and valid procedure. Pers Psychol 60:201–230
Chambers M, Cutcliffe J (2001) The dynamics and processes of ‘ending’ in clinical supervision.
Br J Nurs 10(21):1403–1411
Chambers M, Long A (1995) Supportive clinical supervision: a crucible for personal and profes- sional change. J Psychiatr Ment Health Nurs 2(5):311–316
Clough A (2001) Clinical leadership: turning thought into action. Prim Health Care 11(4):39–41 Connor M (1994) Training the counsellor: an integrative model. Routledge, London
Cottrell S (2001) Occupational stress and job satisfaction in mental health nursing: focused inter- ventions through evidence-based assessment. J Psychiatr Ment Health Nurs 8(2):157–164 Critchley DL (1987) Clinical supervision as a learning tool for the therapist in milieu settings. J
Psychosoc Nurs 25(8):18–22
Cutcliffe JR, Cassedy P (1998) Empathy, students and the problems of genuineness: can we develop empathy on a short skills-based counselling course? Ment Health Pract 1(9):28–33 Cutcliffe JR, Epling M (1997) An exploration of the use of John Heron’s confronting interventions
in clinical supervision: case studies from practice. Psychiatr Care 4(4):174–180
Cutcliffe JR, Hyrkas K, Fowler J (2011) Routledge handbook of clinical supervision: fundamental international themes. Routledge, London
Cutcliffe JR, Proctor B (1998) An alternative training approach to clinical supervision: 1. Br J Nurs 7(5):280–285
Davey B, Desousa C, Robinson S, Murrells T (2006) The policy-practice divide: who has CSCS in nursing? J Res Nurs 11(3):237–248
Day GA (1925) Changing competencies of supervision. Mod Hosp 24(5):469–470
Driscoll J (2000) Practising clinical supervision: a reflective approach. Bailliere Tindall, London Driscoll J (2007) Practising clinical supervision: a reflective approach for health care profession-
als. Bailliere Tindall, London
Farkas-Cameron MM (1995) Clinical supervision in psychiatric nursing: a self-actualising pro- cess. J Psychosoc Nurs Ment Health Serv 33(2):31–37
Faugier J (1994) Thin on the ground. Nurs Times 90(20):64–65
Faugier J (1998) The supervisory relationship. In: Butterworth T, Faugier J, Burnard P (eds) Clinical supervision and mentorship in nursing, 2nd edn. Stanley Thornes, London
Faugier J, Butterworth T (1994) Clinical supervision: a position paper. University of Manchester, Manchester
Fowler J (1995) Nurses perception of the elements of good supervision. Nurs Times 91(22):33–37 Fowler J (1996) Clinical supervision: what do you do after you say hello? Br J Nurs 5(6):382–385 Freeman R (1952) Supervision in the improvement of nursing services. Public Health Nurs
44(7):370–373
Hawkins P, Shohet R (1989) Supervision in the helping professions. Open University Press, Milton Keynes
Heron J (1989) Six category intervention analysis. University of Surrey. Human Potential Resource Group, Guildford
Heron J (1990) Helping the client: a creative practical guide. Sage, London Heron J (2001) Helping the client: a creative practical guide, 5th edn. Sage, London
Johns C, Butcher K (1993) Learning through supervision: a case study of respite care. J Clin Nurs 2(2):89–93
Jones A (2001) Possible influences on clinical supervision. Nurs Stand 16(1):38–42
Jones A (1995) Clinical supervision in sustaining and developing nursing practice. Int J Palliat Nurs 1(4):211–216
Kolb DA (1984) Experiential learning: experience as the source of learning and development.
Prentice-Hall, Englewood Cliffs, NJ
Lynch L, Hancox K, Happell B, Parker J (2008) Clinical supervision for nurses. Wiley, Chichester Manring J, Beitman BD, Dewan MJ (2003) Evaluating competence in psychotherapy. Acad
Psychiatry 27(3):136–144
Milne D (2009) Evidence-based clinical supervision: principles and practice. BPS Blackwell, Oxford
Muecke MA (1970) Video-tape recordings: a tool for psychiatric clinical supervisors. Perspect Psychiatr Care 8(5):200–208
Mulholland J (1994) Competency-based learning applied to nursing management. J Nurs Manag 2(4):161–166
NHS Education for Scotland and The Scottish Government (2008) The matrix: a guide to deliver- ing evidence-based psychological therapies in Scotland. Edinburgh
Nursing Midwifery Council (recovered 2012a) The code: standards of conduct, performance and ethics for nurses and midwives http://standards.nmc-uk.org/PreRegNursing/statutory/back- ground/Pages/more-background-and-context.aspx
Nursing Midwifery Council (recovered 2012b) Guidance on professional conduct for nursing and midwifery students http://www.nmc-uk.org/Documents/Guidance/NMC-Guidance-on- professional-conduct-for-nursing-and-midwifery-students.pdf
Olsen DP (2001) Empathetic maturity: theory of moral point of view in clinical relations. Adv Nurs Sci 24(1):36–46
Padesky C (1996) Developing cognitive therapist competency: teaching and supervision models.
In: Salkovskis PM (ed) Frontiers of cognitive therapy. The Guilford Press, London
Pesut DJ, Williams CA (1990) The nature of clinical supervision in psychiatric nursing: a survey of clinical specialists. Arch Psychiatr Nurs 4(3):188–194
Platt-Koch LM (1986) Clinical supervision for psychiatric nurses. J Psychosoc Nurs 24(1):7–15 Power S (1999) Nursing supervision: a guide for clinical practice. Sage Publications, London