Supervision Meetings Research Articles

Determining the interviewer effect on CQ Index outcomes: a multilevel approach

BackgroundThe CQ Index for the elderly, a quality-of-care questionnaire administered by conducting interviews, is used to assess clients' experiences in Dutch nursing homes and homes for the elderly. This article describes whether inter-interviewer differences influence the perceived quality of healthcare services reported by residents, the size of this interviewer effect and the influence of the interviewer characteristics on CQ Index dimensions for public reporting.MethodsData from 4345 questionnaires was used. Correlations were calculated, reliability analyses were performed, and a multilevel analysis was used to calculate the degree of correlation between two interviewers within one health care institution. Five models were constructed and the Intra Class Correlation (ICC) was calculated. Healthcare institutions were given 1-5 stars on every quality dimensions (1 = worst and 5 = best), adjusted for resident and interviewer characteristics. The effect of these characteristics on the assignment of the stars was investigated.ResultsIn a multilevel approach, the ICC showed a significant amount of variance on five quality dimensions. Of the interviewer characteristics, only previous interviewing experience, the reason of interviewing and general knowledge of health care had a significant effect on the quality dimensions. Adjusting for interviewer characteristics did not affect the overall star assignment to the institutions regarding 7 of 12 quality dimensions. For the other five dimensions (Shared decision-making, Meals, Professional competency, Autonomy, and Availability of personnel) a minor effect was found.ConclusionsWe have shown that training, the use of experienced interviewers, written instructions, supervision and educational meetings do not automatically prevent interviewer effects. While the results of this study can be used to improve the quality of services provided by these institutions, several CQ index dimensions should be interpreted with caution for external purposes (accountability and transparency).

Ricostruzione della storia del paziente. Supervisione psicoanalitica in psichiatria

- It is taken into account one of the functions of the psychoanalytic group clinical thinking within Mental Health Services: the collection-reconstruction of the patient's history. This work, especially in rehabilitation centres where the patient stays for long term periods, allows to relocate the problems and tensions arising from dealing with the patient within a context which grants their comprehension on a deep emotional and thinking level. From that stems an ongoing redefinition of the patient's image and his/her better individualization in the mind of those who look after them. This in turn fosters a consolidation of their own identity as Mental Health professionals. A transcript of two supervision meetings with the staff of a exemplifies some aspects of this work.Key Words: Supervision, Patient's History, Psychosis, Identity, Projective Identification, Rehabilitation, Residential Therapeutic Centre.Parole chiave: supervisione, storia del paziente, psicosi, identitŕ, identificazione proiettiva, riabilitazione, strutture intermedie.

Dilemmas when working with substance abusers with multiple and complex problems: the case manager's perspective

Since the 1990s, case management has been implemented in the USA and Canada – and recently also in various European countries – to support substance abusers with multiple and complex needs. Although this intervention is often presented as a set of standardised functions, its application is often a subjective task involving various dilemmas, which may influence case management outcomes significantly. Based on a comparison of case managers’ experiences in Denmark and Belgium, we focus on several core dilemmas in case management for substance abusers with complex problems. Case management practices vary from one project to the next and even within the same project. Such differences are apparently related to the way in which case managers approach dilemmas such as those existing between control versus self‐determination, or between systematic versus ad‐hoc planning. The conclusion is that it is vital to discuss these dilemmas during training courses and supervision meetings in order to ensure that the intended form of intervention is actually delivered on the ground.

Implementing Mental Health Treatment for Batterer Program Participants

The implementation of a screening and referral system for supplemental mental health treatment among batterer program participants was investigated in a 2-year formative evaluation. The research team conducted direct observation of the agency procedures, participation in training and supervision meetings, debriefing interviews with administrators, and informal conversations with staff and clients. Inconsistencies and breakdowns associated with nearly every step of the screening and referral process were identified, for example, notification of referral instructions and verification of clinical compliance. Court sanctions for referral noncompliance remained inconsistent even during court-mandated referral. Several underlying issues were also exposed: administrative absenteeism and turnover, administrative-staff gaps, client overload, and differing agency priorities. These issues reinforce the challenges facing coordinated community response.

The effects of portfolio-based advice on the development of self-directed learning skills in secondary vocational education

This experimental study was designed to investigate whether supervision meetings, in which students receive specific advice on how to use a development portfolio to monitor their progress and plan their future learning, helps them to develop self-directed learning skills and improve their learning in the domain. In the first year of a hairdressing program in vocational education, supervision meetings were used to provide students with either specific advice or not. Students in the advice group (n = 21) formulated better learning needs, selected more suitable learning tasks, completed more practical assignments, and acquired more certificates than students in the feedback-only group (n = 22). Interviews also showed that students in the advice group appreciated the supervision meeting more and perceived them as more effective than students in the feedback-only group. Guidelines are provided for the use of development portfolios and the organization of supervision meetings in on-demand vocational education.

Reduction of Restraint and Seclusion Through Collaborative Problem Solving: A Five-Year Prospective Inpatient Study

This study examined usage patterns of restraint and seclusion before and after the implementation of collaborative problem solving (CPS), a manualized therapeutic program for working with aggressive children and adolescents. The clinical setting was a 15-bed psychiatric inpatient unit for school-age children. A total of 755 children were hospitalized for a total of 998 admissions from fiscal years 2003 to 2007 (median age=11 years; 64% boys). Data were collected for three years before and 1.5 years after the six-month implementation of the CPS model of care. There were 559 restraint and 1,671 seclusion events during the study period. After implementation of the CPS model there was a reduction in the use of restraints (from 263 events to seven events per year, representing a 37.6-fold reduction, slope [beta]=-.696) and seclusion (from 432 to 133 events per year, representing a 3.2-fold reduction, beta=-.423). The mean duration of restraints decreased from 41+/-8 to 18+/-20 minutes per episode, yielding cumulative unitwide restraint use that dropped from 16+/-10 to .3+/-.5 hours per month (a 45.5-fold reduction, beta=-.674). The mean duration of seclusion decreased from 27+/-5 to 21+/-5 minutes per episode, yielding cumulative unitwide seclusion use that dropped from 15+/-6 to 7+/-6 hours per month (a 2.2-fold reduction; p for trend .01 or better for all slopes). During the early phases of implementation there was a transient increase in staff injuries through patient assaults. CPS is a promising approach to reduce seclusion and restraint use in a child psychiatric inpatient setting. Future research and replication efforts are warranted to test its effectiveness in other restrictive settings.

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

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

Intervenção psicológica em abrigo para mulheres em situação de violência: uma experiência

O objetivo deste artigo é descrever a trajetória da reconstrução da proposta de intervenção psicológica em um abrigo para mulheres em situação de violência intrafamiliar e de gênero. O trabalho iniciou-se com o estabelecimento de encontros de supervisão, no formato de intercontrole, do Serviço de Psicologia. Durante esses encontros, houve uma avaliação das atribuições funcionais, que davam referência ao trabalho até então realizado, e o estabelecimento de uma nova proposta de intervenção. A nova proposta tem como referência principal a necessidade de pensar uma intervenção psicológica em um contexto institucional, considerando a temática do enfrentamento da violência contra a mulher.

Effect of Service Structure and Organization on Staff Care Practices in Small Community Homes for People with Intellectual Disabilities

Background An important question in community living is what factors influence the extent to which staff provide ‘active support’.Methods Engagement, care practices and a range of staff and organizational characteristics were studied in 72 residential homes serving 359 adults with intellectual disabilities. Managers in 36 settings were trained in person‐centred active support (PCAS). A group comparison design and multivariate analysis was used to investigate the relationship between variables.Results The PCAS group showed more active support, assistance, other contact from staff and engagement in meaningful activity but no difference in choice‐making or assessment of participation in activities of daily living. The PCAS group had more staff with a professional qualification, were more likely to think that challenging behaviour was caused by lack of stimulation, had attitudes more in line with a policy of community care, rated most care tasks as less difficult, and were more organized to deliver active support. The comparison group were more likely to think that challenging behaviour was learned negative behaviour, showed more teamwork and were more satisfied. Multivariate analysis identified a range of staff and organizational variables associated with engagement and active support.Conclusions The results suggest that some variables which have not hitherto been studied in relation with active support are associated with it. Professional qualification, knowledge and experience appear to be important as do some staff attitudes, clear management guidance, more frequent supervision and team meetings, training and support for staff to help residents engage in meaningful activity.

Supervision of teachers based on adjusted arithmetic learning in special education

This article reports on 20 children's learning in arithmetic after teaching was adjusted to their conceptual development. The report covers periods from three months up to three terms in an ongoing intervention study of teachers and children in schools for the intellectually disabled and of remedial teaching in regular schools. The researcher classified each child's current counting scheme before and after each term. Recurrent supervision, aiming to facilitate the teachers’ modelling of their children's various conceptual levels and needs of learning, was conducted by the researcher. The teaching content in harmony with each child's ability was discussed with the teachers. This approach gives the teachers the opportunity to experience the children's own operational ways of solving problems. At the supervision meetings, the teachers theorized their practice together with the researcher, ending up with consistent models of the arithmetic of the child. So far, the children's and the teachers’ learning patterns are promising.

"Patient Declined": Contemplating the Psychodynamics of Hospice Music Therapy

ABSTRACT: The literature on music therapy with hospice patients often accentuates the positive aspects of the process and places less emphasis on difficulties the therapist may face. This article examines specific obstacles that may arise when working with dying patients. Four vignettes are presented, which include issues of apathy, depression, anger and frustration. The seemingly overprotective family member scenario is also viewed in relationship to its effect upon the dying patient. A closer look at such difficulties may deepen the understanding of what a person may experience when approaching death. The therapist's reactions to the patient's experiences (countertransference) are explored and emphasized as well. The author's work within the hospice setting was guided in weekly Analytical Music Therapy supervision sessions, whereby, over a period of one year, helpful lessons on coping with patients' rejection were discussed. The lessons and the supervision techniques that were used to teach them are outlined at the conclusion of this article. The title Patient Declined refers both to the psychological issues related to the patient's final physical decline towards death and to the patient's decline of music therapy services. In reviewing the growing body of literature on the topic of hospice music therapy, I have found that the case descriptions focus almost exclusively on the patient's problems and/or decline and much less on the therapist's challenges or difficulties, perhaps out of respect to the topic of death, or to the memory of the deceased patients. Additionally, the cases that are brought forward in the literature usually end on a positive, comforting note. In contrast, in this article, I chose to focus on the difficulties that I faced in my work at a home-based hospice agency. These difficulties associated with the process of dying resulted in patients declining music therapy services and were brought to my weekly Analytical Music Therapy supervision meetings to be analyzed in depth with the support of my supervisor. This article summarizes one full year of therapy sessions and supervision meetings. The purpose of this article is to examine and analyze some of the difficulties that may arise, for patients and therapists alike, when working with people who are dying. Four vignettes are presented, focusing on patients with apathy, depression, anger, and frustration. The hardship of working with family members who are seemingly overly protective is presented as well. There has been a valuable discussion in the music therapy literature regarding the various needs and problems of hospice patients (e.g., Gilbert, 1977; Krout, 2000; Maue-Johnson & Tanguay, 2006; West, 1994). Unlike previous writings, however, this article includes an examination of possible psychological issues that may arise within the therapist as a response to the patient's problems. In addition, it presents some of the most helpful lessons that were learned in supervision through the supervisory techniques that were used to teach them. Since the supervision was anchored in the theoretical perspective of Analytical Music Therapy, some of the key theoretical highlights of this method are featured, specifically, discussions of countertransference and the possible defenses that are parallel within the patients and the therapist. Clarification of Terms In my training and philosophical background, I am an Analytical Music Therapist. Analytical Music Therapy (AMT) is an indepth music therapy method pioneered by Mary Priestley in the early 1970's in Great Britain. Based on the concepts of Freud, Klein, and Jung, the underlying theory of this method acknowledges the existence of an unconscious and identifies its effects on people's behaviors. AMT presumes that in any therapeutic relationship conscious and unconscious feelings of the client towards the therapist (transference) and of the therapist towards the client (countertransference) are inter-related and may affect the course of the therapy (Priestley, 1994). …

'I believe that the staff have reduced their closeness to patients': an exploratory study on the impact of HIV/AIDS on staff in four rural hospitals in Uganda

BackgroundStaff shortages could harm the provision and quality of health care in Uganda, so staff retention and motivation are crucial. Understanding the impact of HIV/AIDS on staff contributes to designing appropriate retention and motivation strategies. This research aimed 'to identify the influence of HIV/AIDS on staff working in general hospitals at district level in rural areas and to explore support required and offered to deal with HIV/AIDS in the workplace'. Its results were to inform strategies to mitigate the impact of HIV/AIDS on hospital staff.MethodsA cross-sectional study with qualitative and quantitative components was implemented during two weeks in September 2005. Data were collected in two government and two faith-based private not-for-profit hospitals purposively selected in rural districts in Uganda's Central Region. Researchers interviewed 237 people using a structured questionnaire and held four focus group discussions and 44 in-depth interviews.ResultsHIV/AIDS places both physical and, to some extent, emotional demands on health workers. Eighty-six per cent of respondents reported an increased workload, with 48 per cent regularly working overtime, while 83 per cent feared infection at work, and 36 per cent reported suffering an injury in the previous year. HIV-positive staff remained in hiding, and most staff did not want to get tested as they feared stigmatization. Organizational responses were implemented haphazardly and were limited to providing protective materials and the HIV/AIDS-related services offered to patients. Although most staff felt motivated to work, not being motivated was associated with a lack of daily supervision, a lack of awareness on the availability of HIV/AIDS counselling, using antiretrovirals and working overtime. The specific hospital context influenced staff perceptions and experiences.ConclusionHIV/AIDS is a crucially important contextual factor, impacting on working conditions in various ways. Therefore, organizational responses should be integrated into responses to other problematic working conditions and adapted to the local context. Opportunities already exist, such as better use of supervision, educational sessions and staff meetings. However, exchanges on interventions to improve staff motivation and address HIV/AIDS in the health sector are urgently required, including information on results and details of the context and implementation process.

Organizational and individual factors associated with breakdown of residential placements for people with intellectual disabilities

People with intellectual disabilities (IDs) whose behaviour challenges services are at increased risk of placement breakdown. Most previous research has tended to focus on the role of individual characteristics in predicting breakdown. A small number of studies have suggested that service variables may impact on intervention effectiveness and hence placement breakdown. This study used a non-experimental group comparison design to investigate potential differences between two groups of residential homes, one of which had experienced placement breakdown, and one of which had successfully maintained placements in the community. More residents in the breakdown group had inappropriate sexual behaviours but there were no other differences. Services in the breakdown group had more limited procedural guidance for staff, weaker training, supervision and team meetings and less external professional support. Placement characteristics may be an important determinant of community placement success for people with IDs and challenging behaviour. Those selecting and funding residential placements for such people should attend to the technical competence of the placement (in terms of its use of procedural guidance, training and professional advice) and to the extent of support for staff (in terms of training, supervision and team meetings).

AMEE Guide No. 27: Effective educational and clinical supervision

Background: This guide reviews what is known about educational and clinical supervision practice through a literature review and a questionnaire survey. It identifies the need for a definition and for explicit guidelines on supervision. There is strong evidence that, whilst supervision is considered to be both important and effective, practice is highly variable. In some cases, there is inadequate coverage and frequency of supervision activities. There is particular concern about lack of supervision for emergency and ‘out of hours work’, failure to formally address under-performance, lack of commitment to supervision and finding sufficient time for supervision. There is a need for an effective system to address both poor performance and inadequate supervision.Supervision is defined, in this guide as: ‘The provision of guidance and feedback on matters of personal, professional and educational development in the context of a trainee's experience of providing safe and appropriate patient care.’ A framework for effective supervision is provided:(1) Effective supervision should be offered in context; supervisors must be aware of local postgraduate training bodies’ and institutions’ requirements; (2) Direct supervision with trainee and supervisor working together and observing each other positively affects patient outcome and trainee development; (3) Constructive feedback is essential and should be frequent; (4) Supervision should be structured and there should be regular timetabled meetings. The content of supervision meetings should be agreed and learning objectives determined at the beginning of the supervisory relationship. Supervision contracts can be useful tools and should include detail regarding frequency, duration and content of supervision; appraisal and assessment; learning objectives and any specific requirements; (5) Supervision should include clinical management; teaching and research; management and administration; pastoral care; interpersonal skills; personal development; reflection; (6) The quality of the supervisory relationship strongly affects the effectiveness of supervision. Specific aspects include continuity over time in the supervisory relationship, that the supervisees control the product of supervision (there is some suggestion that supervision is only effective when this is the case) and that there is some reflection by both participants. The relationship is partly influenced by the supervisor's commitment to teaching as well as both the attitudes and commitment of supervisor and trainee; (7) Training for supervisors needs to include some of the following: understanding teaching; assessment; counselling skills; appraisal; feedback; careers advice; interpersonal skills. Supervisors (and trainees) need to understand that: (1) helpful supervisory behaviours include giving direct guidance on clinical work, linking theory and practice, engaging in joint problem-solving and offering feedback, reassurance and providing role models; (2) ineffective supervisory behaviours include rigidity; low empathy; failure to offer support; failure to follow supervisees’ concerns; not teaching; being indirect and intolerant and emphasizing evaluation and negative aspects; (3) in addition to supervisory skills, effective supervisors need to have good interpersonal skills, good teaching skills and be clinically competent and knowledgeable.

Nursing assistants’ behaviour during morning care: effects of the implementation of snoezelen, integrated in 24‐hour dementia care

This paper reports an investigation of the effects of the implementation of snoezelen, or multisensory stimulation, on the quality of nursing assistants' behaviour during morning care. Nursing assistants in long-term dementia care are often unaware of the impact of their behaviour on patient functioning. Snoezelen is a psychosocial intervention that might improve the quality of caregiver behaviour by combining a person-centred approach with the integration of sensory stimuli. A quasi-experimental pre- and post-test design was implemented in 12 wards for older mentally infirm patients at six nursing homes. The experimental group intervention was a 4-day in-house 'snoezelen' training, stimulus preference screening and supervision meetings. The control group received usual nursing home care. The effectiveness of the intervention was studied by analysing 250 video recordings, which were assessed by independent observers using a 4-point measurement scale developed for this study and based on Kitwood's Dialectical Framework. The results showed a statistically significant increase in 'Positive Person Work' and decrease in 'Malignant Social Psychology' (total scores) after the implementation of snoezelen. Nursing assistants in the experimental group also improved by statistically significant amounts on all subitems of 'Positive Person Work'. The mean number of sensory stimuli, offered explicitly, increased. The implementation of snoezelen succeeded in effecting a change to a more person-centred approach during morning care. The results indicate that nursing assistants' behaviour can be positively changed provided that the new care model has been successfully implemented.

Book Review

The Ethics of New Reproductive Technologies: Cases and Questions. Edited by Dolores Dooley, Panagiota Dalla-Vorgia, Tina Garanis-Papadatos, and Joan McCarthy. Berghahn Books, New York, 2003, 214 pp., $49.95. Ethics and Genetics: A Workbook for Practitioners and Students. Edited by Guido de Wert, Ruud ter Meulen, Roberto Mordacci, and Mariachiara Tallacchini. Berghahn Books, New York, 2003, 152 pp., $42.00. Issues in Medical Research Ethics: A Workbook for Practitioners and Students. Edited by Jürgen Boomgaarden, Pekka Louhiala, and Urban Wiesing. Berghahn Books, New York, 2003, 136 pp., $42.00. This is a three volume series of primarily teaching texts concentrating on three broad areas of bioethics reflecting major challenges to practitioners in Europe but the issues and discussions easily translate to the same areas of practice worldwide. The materials are designed for readers with no formal training in bioethics. The authors use case examples, challenging questions and expert commentary to direct the reader to contemplate the ethical issues common to the disciplines of genetics, reproductive technologies and medical research. These books are organized well for teaching purposes with illustrative examples of issues and interactive discussion activities sprinkled throughout background information and commentaries. Moreover, the challenges spotlighted would also serve as wonderful discussion material for peer supervision meetings, professional educational meetings or for personal reflection. I found the materials enjoyable, easily readable and very thought provoking forcing me to think about what I do or would do in certain situations and more importantly, why I would make those choices and others would choose differently. Volume 1 focuses on issues foremost in new reproductive technologies. The authors provide a way of presenting and discussing these issues that is respectful of differing opinions. They use the concept of moral responsibility to help the reader think about how people in different situations might not see things in the same way. Many of the case examples used are well related to the practice of genetic counseling. Volume 2 focuses on genetics, specifically genetics in medicine. Before reading these texts, I thought I would enjoy this volume the most as I believed I would be able to relate best to the issues discussed. It is true that the issues discussed in this volume are directly related to the practice of genetic counseling however, I found several instances of good, but not totally accurate or complete information about a disorder and this was very distracting to me. The authors used the example of an incidental finding of Klinefelter syndrome found on prenatal testing. The case made it clear that the parents were never told of anything other than Down syndrome prior to testing so the finding of another chromosome abnormality was quite a surprise. In addition, the description of Klinefelter syndrome was somewhat incomplete and I found this distressful especially because the couple was to use this information to decide about the management of the pregnancy. In another case, the authors use a very incomplete picture of Huntington disease to set the discussion about prenatal testing for late onset disease. I found myself thinking about how the arguments would be different if the information was more complete and this distracted me from thinking about the big picture that the authors were attempting to illustrate. Having said that, the case examples used are good ones right from the genetic counseling practice and the challenging questions and discussion sections were excellent. Again, the authors are careful and skilled at helping the reader understand differing points of view. Volume 3 centers on the ethical issues in medical research. Because the authors are using European case examples with European law and regulations in the discussions, some of the materials may not be directly transferable to US research practice however, the concepts are universal. The case examples are up-to-date and they challenge the reader to examine their beliefs about ethical behavior in research. The authors examine the subtleties involved in coercion and informed consent. Of particular interest to me was the discussion about blurred roles in research where the practitioner is both the researcher and professional providing medical care for the subject/patient. This dilemma is discussed in terms of conflicting obligations for the physician researcher but it is easy to see how this is a dilemma for any health care provider also involved in research. It is interesting to note that the discussion for this section is titled, “The irresolvable ethical dilemma of clinical research.” One cannot pass up a challenge like that. In summary, I very much enjoyed reading these texts. I found the case examples, challenging questions and discussions thought provoking and fun. I also believe much of the materials would be excellent for teaching students in a wide variety of settings. These books would be good additions to a genetic counseling teaching library.

Using Action Research to Address Loss of Personhood in a Continuing Care Setting

This article describes a three-year action research project, aimed to support staff in recognizing and responding to loss of personhood in a continuing care setting. The context of this study was a U.K. National Health Service (NHS) nursing home for the long-term care of older people. Interventions used to support this development included the collection and sharing of residents' life histories, weekly team supervision meetings for staff, an action learning set for managers, and monthly external supervised meetings for both the action researcher and senior manager. This article reports on the processes and outcomes of change achieved and the learning gained from working in a collaborative way with staff. Given that current policy indicates the need for person-centered care, this study provides a possible mechanism for putting it into practice through a systems and psychodynamically informed approach.

Clinical Computing: A Web-Based Data Management System to Improve Care for Depression in a Multicenter Clinical Trial

Clinical Computing: A Web-Based Data Management System to Improve Care for Depression in a Multicenter Clinical Trial

A web-based data management system to improve care for depression in a multicenter clinical trial.

A web-based data management system to improve care for depression in a multicenter clinical trial.

Some experiences of professional practice and beneficial changes derived from clinical supervision by community Macmillan nurses.

This is a report of an interpretative study that explored some 'lived experiences' of community Macmillan nurses as they recounted them during clinical supervision meetings. This discussion is concerned with serious illness, dying and bereavement and the potential of supervision to reach the 'life-world' of professional practice but also potential benefits for Macmillan nurses. Accounts of professional practice are considered in the context of clinical supervision meetings. Five nurses--four women and one man--undertook individual clinical supervision with the researcher for 6 months over three phases for 18 months in total. Meetings took place in the clinics and health centres in which the Macmillan nurses worked. The method of clinical supervision drew on and developed established ideas from the health science literatures to guide supervisory practice. A synthesis of psychoanalytic ways of thinking and existential phenomenology provided a framework for understanding the data. Five salient themes were identified as emerging from accounts of professional practice: Biographical Determinants, Compulsion, Existential Concerns, Empathic Insufficiency in the Organisation of Palliative Care and Empathic Attainment in the Organisation of Palliative Care. The study shows a need to consider structuring environments that both help and protect community Macmillan nurses and fellow workers. Methods of clinical supervision should be informed by and complement lived experiences of working with serious illness, dying and bereavement.