Clinical supervision in the mental health nursing workforce: a qualitative analysis of an expert community of practice

This study explores the experiences and perceptions of clinicians from a range of professions to articulate general principles for clinical supervision in mental health. Seventy-seven volunteer clinicians participated in 14 focus groups in 2008–2009. They discussed their perceptions about clinical supervision, facilitators, and barriers. Discussions were digitally recorded and transcribed verbatim, and qualitative analytic methods were used to identify themes and exceptions. The study found frontline clinicians identified interacting factors they associated with quality clinical supervision. Themes related to the structure, content, and process of supervision and contained common elements across professions and those that were specific to nursing. Considerable agreement exists regarding principles for interprofessional supervision in mental health; that it is available on a regular and crisis-responsive basis, and that supervisors are expert in clinical interventions for specific populations and have the skills for teaching and supporting staff. Some nurse participants expressed unique perceptions about clinical supervision based on their professional traditions and approaches, which requires further study before advancing a common model of supervision across professions.

Although safety climate, teamwork, and other non-technical skills in operating rooms probably influence clinical outcomes, direct associations have not been shown, at least partially due to sample size considerations. We report data from a retrospective cohort of anesthesia evaluations that can simplify the design of prospective observational studies in this area.Associations between non-technical skills in anesthesia, specifically anesthesiologists' quality of clinical supervision and nurse anesthetists' work habits, and patient and operational factors were examined. Eight fiscal years of evaluations and surgical cases from one hospital were included. Clinical supervision by anesthesiologists was evaluated daily using a nine-item scale. Work habits of nurse anesthetists were evaluated daily using a six-item scale. The dependent variables for both groups of staff were binary, whether all items were given the maximum score or not. Associations were tested with patient and operational variables for the entire day. There were 40,718 evaluations of faculty anesthesiologists by trainees, 53,772 evaluations of nurse anesthetists by anesthesiologists, and 296,449 cases that raters and ratees started together. Cohen's d values were small (≤0.10) for all independent variables, suggesting a lack of any clinically meaningful association between patient and operational factors and evaluations given the maximum scores. For supervision quality, the day's count of orthopedic cases was a significant predictor of scores (P = 0.0011). However, the resulting absolute marginal change in the percentage of supervision scores equal to the maximum was only 0.8% (99% confidence interval: 0.2% to 1.4%), i.e., too small to be of clinical or managerial importance. Neurosurgical cases may have been a significant predictor of work habits (P = 0.0054). However, the resulting marginal change in the percentage of work habits scores equal to the maximum, an increase of 0.8% (99% confidence interval: 0.1% to 1.6%), which was again too small to be important. When evaluating the effect of assigning anesthesiologists and nurse anesthetists with different clinical performance quality on clinical outcomes, supervision qualityand work habits scores may be included as independent variables without concern that their effects are confounded by association with the patient or case characteristics. Clinical supervision and work habits are measures of non-technical skills. Hence, these findings suggest that non-technical performance can be judged by observing the typical small sample size of cases. Then, associations can be tested with administrative data for a far greater number of patients because there is unlikely to be a confounding association between patient and case characteristics and the clinicians' non-technical performance.

This is an important and timely book because inquiries into mental health service tragedies usually pinpoint deficits around leadership, the orientation of staff and communication.

Our department monitors the quality of anesthesiologists' clinical supervision and provides each anesthesiologist with periodic feedback. We hypothesized that greater differentiation among anesthesiologists' supervision scores could be obtained by adjusting for leniency of the rating resident. From July 1, 2013 to December 31, 2015, our department has utilized the de Oliveira Filho unidimensional nine-item supervision scale to assess the quality of clinical supervision provided by faculty as rated by residents. We examined all 13,664 ratings of the 97 anesthesiologists (ratees) by the 65 residents (raters). Testing for internal consistency among answers to questions (large Cronbach's alpha > 0.90) was performed to rule out that one or two questions accounted for leniency. Mixed-effects logistic regression was used to compare ratees while controlling for rater leniency vs using Student t tests without rater leniency. The mean supervision scale score was calculated for each combination of the 65 raters and nine questions. The Cronbach's alpha was very large (0.977). The mean score was calculated for each of the 3,421 observed combinations of resident and anesthesiologist. The logits of the percentage of scores equal to the maximum value of 4.00 were normally distributed (residents, P = 0.24; anesthesiologists, P = 0.50). There were 20/97 anesthesiologists identified as significant outliers (13 with below average supervision scores and seven with better than average) using the mixed-effects logistic regression with rater leniency entered as a fixed effect but not by Student's t test. In contrast, there were three of 97 anesthesiologists identified as outliers (all three above average) using Student's t tests but not by logistic regression with leniency. The 20 vs 3 was significant (P < 0.001). Use of logistic regression with leniency results in greater detection of anesthesiologists with significantly better (or worse) clinical supervision scores than use of Student's t tests (i.e., without adjustment for rater leniency).

Implementation of Integrated Dual Disorders Treatment: A Qualitative Analysis of Facilitators and Barriers

Objective The aim of this study was to identify the factors contributing to high-quality clinical supervision of the allied health workforce in rural and remote settings. Methods This quantitative study was part of a broader project that used a mixed-methods sequential explanatory design. Participants were 159 allied health professionals from two Australian states. Quantitative data were collected using an online customised survey and the Manchester Clinical Supervision Scale (MCSS-26). Data were analysed using regression analyses. Results Supervisee's work setting and choice of supervisor were found to have a positive and significant influence on clinical supervision quality. Supervisee profession and time in work role were found to have a negative and significant influence on the quality of clinical supervision. Conclusions High-quality clinical supervision is essential to achieve quality and safety of health care, as well as to support the health workforce. Information on high-quality clinical supervision identified in this study can be applied to clinical supervision practices in rural and remote settings, and to professional support policies and training to enhance the quality of supervision. What is known about the topic? There is mounting evidence on the benefits of clinical supervision to health professionals, organisations and patients. Clinical supervision enhances recruitment and retention of the health workforce. However, there are still gaps regarding the factors that contribute to high-quality clinical supervision, especially for rural and remote health professionals. What does this paper add? This study, the first of its kind, recruited rural and remote health professionals from seven allied health disciplines across two Australian states. It investigated the factors that influence high-quality clinical supervision in this under-resourced group. This paper outlines specific factors that contribute to clinical supervision quality for rural and remote allied health professionals. What are the implications for practitioners? Effective and high-quality clinical supervision of the rural and remote allied health workforce can enhance recruitment and retention in those areas. Healthcare organisations can facilitate effective clinical supervision delivery by using the evidence gathered in this study in clinical supervision policy, training and practice.

This study aims to explore the value and meaning of a psychodynamic work discussion for mental health nurses, and its potential as an approach in staff clinical supervision. Data were generated by using a focus group with a purposive sample of six mental health nurses, and analysed by the 'collapsing of data' from labels to form categories and formulate themes. The findings suggest that staff emotion generated from clinical work is dealt with in many personal ways though rarely in clinical supervision. Although the idea of a work discussion group is not readily known among the focus group, staff appear to be open to its potential to provide a helpful emotional perspective. Education in the form of an introduction and exposure to some basic psychodynamic ideas could provide the first step towards unlocking its potential. Sharing personal experiences of an emotional nature within a safe, secure environment seems significant in this education process.

Clinical supervision is pivotal in supporting nurses in rendering quality, safe patient care. Therefore, it is essential to understand clinical supervision from operational nursing managers' context to define existing challenges and propose suitable recommendations. This study aimed to explore and describe operational nursing managers' experiences of clinical supervision within the context of an academic hospital in Gauteng province and propose evidence-based practice recommendations to improve patient safety and the quality of clinical supervision. An exploratory, sequential, mixed-method design was used and implemented over two phases to take advantage of the strengths of both the qualitative and quantitative research designs. Unstructured individual interviews were conducted to collect data in phase one, and an adapted Manchester Clinical Supervision Scale (MCSS) questionnaire was used to collect data in phase two. Operational nursing managers work in stressful conditions and environments with a gross shortage of staff and tools of the trade while being expected to deliver high-quality and safe nursing care. Of the sampled respondents, 36% (n= 17) were dissatisfied with the supervision they received, while 64% (n= 30) were indifferent in the sense that they did not think it was adequate or inadequate. Clinical supervisors should be trained and supported in clinical supervision, with regular workshops on interpersonal relations.Contribution:A clearer understanding of clinical supervision within the hospital context and evidence-based practice recommendations to improve patient safety and the quality of clinical supervision.

Aims We have completed a cycle of audit on the availability and quality of clinical supervision in Somerset NHS Foundation Trust. Last year we had highlighted the results of our first survey (run in 2020) in local teaching and audit meetings. We have now completed the cycle following the intervention. Both Severn deanery and Somerset NHS Foundation Trust both recommend psychiatry trainees have one hour of supervision per week, involving exploration of trainee clinical and educational needs. This audit is now part of a quality improvement project being run across Severn Deanery. This particular audit focuses on the results from Somerset NHS Foundation Trust. Methods Trainees working in Somerset NHS Foundation Trust were invited to participate in this survey. We used the original survey from last year but added further white spaces to invite feedback and to explore what was particularly good about the clinical supervision currently offered. Questions on accomplishing workplace based assessments (WPBA), managing e-portfolio requirements were asked, with Likert scale responses available. The survey was sent out in the form of Microsoft Forms disseminated via email to all junior doctors (n = 27). Survey was run from May till June 2021 (nearing the end of placement). We sent out 3 reminders before closing the survey. The authors of the audit then reviewed the data. Results 9 out of 27 doctors responded, response rate of 33%. Our last survey had a response rate of 63%. Supervision appears to be more regular now with only 11% stating that they were meeting their supervisor sometimes in comparison to 17% the last survey. Similar percentage of respondents were able to complete WBPAs as in the last survey (88% Vs 89%). QI project/audits were being discussed at a similar rate (60% Vs 66%). 75% of psychiatry trainee respondents were discussing their psychotherapy competencies (42% were having some discussion in the last survey). There was a better response from GP and FY doctors for this survey. Conclusion Response rate appears to have fallen, however supervision appears to be more regular with more focus on competencies. White space answers showed that most trainees were satisfied with supervision. However, supervision could be more consistent and serious attempts must be made to protect it from clinical work overshadowing it. We will be comparing the results of our audit in Somerset NHS Foundation Trust to the results from other parts of the deanery.

Objective:Public mental health settings experience severe recruitment and retention challenges, with many providers leaving for more lucrative private practice settings. This mixed-methods study examined private practice providers’ reasons for leaving public mental health settings as well as their experiences and perceptions of the differences between both settings.Methods:Private practice mental health providers participated in a nationwide, online survey. Providers responded to closed- and open-ended questions, which assessed their reasons for leaving public mental health settings and their perceptions of the differences in care delivery between both settings. Their quantitative responses were descriptively characterized, and their qualitative responses were analyzed using content analysis.Results:Three hundred seven licensed mental health providers completed the survey. Most providers (60%) had previously worked in a public mental health setting, and most of them reported leaving for higher wages (86%) and greater independence and flexibility (82%). In open-ended responses, providers emphasized that private practice has far more advantages than public mental health settings. They emphasized that private practice offers providers freedom and autonomy to practice clinically in the way that they wish, set their own schedules and working conditions, select the clients they want to work with, and decide their preferred caseload volume.Conclusions:Study findings align with commonly reported challenges of working in public mental health settings and underscore a unique advantage of private practice: provider freedom and autonomy. Policies are needed to enhance the public mental health workforce’s material working conditions and sense of autonomy to recruit and retain providers in public settings.

A study was conducted to assess the quality of clinical learning environment and supervision among BSc nursing students of a selected college, Ernakulam. From two batches, a total of 99 samples were selected by total enumeration sampling fulfilling the inclusion criteria. Using the clinical learning experience and supervision scale, data was collected and analysed with descriptive and inferential statistics. The major findings were 73 % students reported that the quality of clinical learning environment and supervision as excellent and 26.26 % reported as good while none of them reported as average. Majority (86 %) of first year BSc nursing students when compared to second year BSc nursing students (61.3 %) reported that the quality of clinical learning environment and supervision as excellent. The study concluded that nursing students were satisfied with the quality of clinical learning environment and supervision and by their contribution to fulfilment of overall learning outcomes and emphasize the potential of clinical supervision to contribute to personal growth and a caring attitude towards patients, thereby ensuring patient safety. Keywords: Clinical learning environment, clinical supervision, clinical experience

At all Joint Commission-accredited hospitals, the anesthesia department chair must report quantitative assessments of anesthesiologists' and nurse anesthetists' (CRNAs') clinical performance at least annually. Most metrics lack evidence of usefulness, cost-effectiveness, reliability, or validity. Earlier studies showed that anesthesiologists' clinical supervision quality and CRNAs' work habits have content, convergent, discriminant, and construct validity. We evaluated predictive validity by testing for (expected) small but statistically significant associations between higher quality of supervision (work habits) and reduced probabilities of cases taking longer than estimated. Supervision quality of each anesthesiologist was evaluated daily by assigned trainees using the 9-item de Oliveira Filho scale. The work habits of each CRNA were evaluated daily by assigned anesthesiologists using a 6-item scale. Both are scored binary, 1 if all items are rated the maximum, 0 otherwise. From 40,718 supervision evaluations and 53,722 work habit evaluations over 8 fiscal years, 16 mixed-effects logistic regression models were estimated, with raters as fixed effects and ratees (anesthesiologists or CRNAs) as random effects. Empirical Bayes means in the logit scale were obtained for 561 anesthesiologist-years and 605 CRNA-years. The binary-dependent variable was whether the case took longer than estimated from the historical mean time for combinations of scheduled procedures and surgeons. From 264,060 cases, 8 mixed-effects logistic regression models were fitted, 1 per fiscal year, using ratees as random effects. Predictive validity was tested by pairing the 8 one-year analyses of clinical supervision, and the 8 one-year analyses of work habits, by ratee, with the 8 one-year analyses of whether OR time was longer than estimated. Bivariate errors in variable linear least squares linear regressions minimized total variances. Among anesthesiologists, 8.2% (46/561) had below-average supervision quality, and 17.7% (99/561), above-average. Among CRNAs, 6.3% (38/605) had below-average work habits, and 10.9% (66/605) above-average. Increases in the logits of the quality of clinical supervision were associated with decreases in the logits of the probabilities of cases taking longer than estimated, unitless slope = -0.0361 (SE, 0.0053), P < .00001. Increases in the logits of CRNAs' work habits were associated with decreases in the logits of probabilities of cases taking longer than estimated, slope = -0.0238 (SE, 0.0054), P < .00001. Predictive validity was confirmed, providing further evidence for using supervision and work habits scales for ongoing professional practice evaluations. Specifically, OR times were briefer when anesthesiologists supervised residents more closely, and when CRNAs had better work habits.

The Department of Health (DoH, 1994) advocated the introduction of clinical supervision into mental health nursing practice and suggested that student nurses be prepared in what to expect from this process. The ENB (1995) supported this recommendation but has offered no guidelines on how it is meant to be implemented. This article reports on an educational initiative in which group supervision was implemented within one cohort of preregistration mental health nursing students. The students reported a number of perceived benefits: a greater understanding of the purpose and benefits of clinical supervision; skill development; the opportunity to reflect on practice; and the reduction of stress.

A large proportion of Australians are affected by mental illness each year, and treatment gaps are well known. To meet current and future demands and enable access to treatment that is safe, effective, and acceptable, a robust and sustainable mental health workforce is required. Factors reported to attract people to work within the mental health sector include aspiring to help others, having an interest in mental health and human behavior, the desire to make a difference and do something worthwhile, personal lived experience, recognition, and value of discipline-specific roles. However, despite the various reasons people enter the public mental health workforce, recruitment and retention continue to be ongoing challenges. To date, there has been limited investigation into understanding which factors are most relevant to the current Victorian workforce. Furthermore, a comparison to health care workers outside of mental health is also needed to better understand the specific needs of staff within the mental health sector. This study aims to explore factors related to attraction, recruitment, and retention of the public mental health workforce in Victoria, Australia. The study is a multisite, mixed methods cross-sectional study to be conducted at 4 public hospital services within Victoria, Australia: 2 in metropolitan and 2 in regional or rural locations. Current, previous, and nonmental health workers will be asked to complete a 20-25-minute web-based survey, which is developed based on previous research and offered participation in an optional 30-60-minute semistructured interview to examine personal experiences and perceptions. Both aspects of the project will examine factors related to attraction, recruitment, and retention in the public mental health workforce. Differences between groups (ie, current, past, and nonmental health workers), as well as location, discipline, and health setting will be examined. Regression analyses will be performed to determine the factors most strongly associated with retention (ie, job satisfaction) and turnover intention. Qualitative data will be transcribed verbatim and thematically analyzed to identify common themes. As of May 2023, we enrolled 539 participants in the web-based survey and 27 participants in the qualitative interview. This project seeks to build on current knowledge from within Australia and internationally to understand role and service/system-related issues of attraction, recruitment, and retention specifically within Victoria, Australia. Seeking up-to-date information from across the health workforce may provide factors specific to mental health by illuminating any differences between mental health workers and health care workers outside of mental health. Furthermore, exploring motivators across health care disciplines and locations to enter, stay in, or leave a role in public mental health settings will provide valuable information to support how the sector plans and develops strategies that are fit for purpose. DERR1-10.2196/48855.

Back to table of contents Next article Taking IssueFull AccessThe Rising Toll of Public Mental Health WorkMark Baptiste, M.D., and Rachel Talley, M.D.Mark BaptisteSearch for more papers by this author, M.D., and Rachel TalleySearch for more papers by this author, M.D.Published Online:1 Jul 2022https://doi.org/10.1176/appi.ps.22073007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Severe mental health workforce shortages and high rates of health care worker burnout have been highlighted as key priority areas to address the U.S. national mental health crisis. Briana S. Last and colleagues (1) present timely findings that underscore the urgency of these priorities. The authors elucidate several facets of the emotional and financial strain experienced by public mental health workers in Philadelphia and demonstrate an inverse association between level of education debt and frequency of evidence-based intervention (EBI) delivery. These findings are alarming but not surprising based on our frontline experience providing clinical care and training in multidisciplinary public mental health settings. Consistent with this study’s findings, we have found that low compensation, high workload driven by volume-based payer incentives, and constant exposure to psychosocially complex and chronically traumatized populations are the ingredients for burnout and high turnover. Despite the best efforts of frontline clinicians and local behavioral health and payer authorities such as those in Philadelphia, these forces can become unsurmountable barriers to sustained uptake of EBIs in settings where they are most needed.Most clinicians in this study needed to work an additional job to supplement their income and carried significant education debt. The authors rightly highlight the crippling effect of low Medicaid reimbursement rates and fee-for-service (FFS) payment models on financial stability and ability to provide appropriate compensation in public mental health settings. Further, FFS financially incentivizes and rewards volume, potentially sacrificing quality. Continuously embedding an EBI can require both initial short-term training/supervision and longer-term, “refresher” venues for training, particularly with staff turnover. In overburdened and understaffed public FFS settings, consistently protecting clinician time for training in EBI is hardly feasible; these tasks compete with the pressure to generate billable encounters. Time and volume demands are uniquely burdensome in public settings because clinicians are charged with applying EBIs from research study conditions to complex populations with multiple comorbid clinical and psychosocial issues. When system financial constraints limit case management access, patients often look to clinicians to assist, further absorbing clinical time. These conditions make the consistent delivery of EBI impossible.Higher rates of reimbursement, increased use of episode-of-care payments with appropriate rates, and increased use of value- and performance-based payment rewarding evidence-based care are critically needed to increase the financial ability of public mental health systems to properly compensate their staff and align payment incentives with delivery of EBI. In addition to these system-level solutions, we applaud Ms. Last and colleagues for suggesting how increased financial resources could be prioritized to directly benefit individual clinicians. We underscore Last and colleagues’ suggestions of compensated ongoing consultation in EBI on the job and wage incentives for use of EBI. Well-intentioned efforts to implement new clinical interventions often do not account for the extra time and energy clinicians require to learn and effectively use these strategies.When a precarious personal financial situation combines with the volume-focused pressure of FFS and the complex conditions of patients in public mental health settings, seeing clinicians experience burnout and secondary stress response is not surprising. High rates of secondary traumatic stress, burnout, and posttraumatic stress disorder in the study’s sample are particularly alarming when coupled with clinician-reported difficulties in affording mental health care. Staff burnout and resultant turnover complicate the ability of public mental health systems to provide consistent long-term provider-patient relationships and care, whether evidence based or not. Beyond the authors’ suggestions of increased peer and supervisory support, benefits covering mental health care and robust employee assistance programs with trauma-informed resources should be considered a mandatory part of trauma-focused EBI intervention, just as is training in the intervention itself. The increased move toward hiring independent contractors removes critical mental health supports for employees.Despite the passion and dedication of frontline public mental health workers, the current financial and emotional toll of their work settings not only stymies sustained uptake of EBI but also threatens the sustainability of this work as a long-term career path. Without significant investment in the financial and emotional well-being of this workforce, we fear a continued migration of talented public mental health clinicians to the private sector.Department of Psychiatry, University of Pennsylvania, Philadelphia.Send correspondence to Dr. Baptiste ([email protected]).Reference1 Last BS, Schriger SH, Becker-Haimes EM, et al.: Economic precarity, financial strain, and job-related stress among philadelphia’s public mental health clinicians. Psychiatr Serv 2022; 73:774–786Abstract, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 73Issue 7 July 2022Pages 721-721 Metrics PDF download History Published online 1 July 2022 Published in print 1 July 2022