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PROTOCOL: Effects of clinical supervision of mental health professionals on supervisee knowledge, skills, attitudes and behaviour, and client outcomes: protocol for a systematic review

2017; The Campbell Collaboration; Volume: 13; Issue: 1 Linguagem: Inglês

10.1002/cl2.179

1891-1803

Robert Allan, Alan McLuckie, Lillian Hoffecker,

Counseling, Therapy, and Family Dynamics

Clinical supervision is increasingly being recognized as a core professional competency within the mental health field (Brosan, Reynolds, & Moore, 2008). Supervision is also considered an essential component of modern effective health care systems (Kadushin, 2002) and training programs for mental health professionals (Berger & Mizrahi, 2001; Milne, Sheikh, Pattison, & Wilkinson, 2011; Watkins, 2011). The terms mental health professional is used here to refer to all clinicians working in the mental health field, including psychotherapists, counsellors, social workers, psychologists, psychiatrists, nurses, pastoral counsellors and couple/marriage and family therapists as well as trainees in each of these professions. Similarly, the term mental health work refers to the clinical work for each of these professions, which includes, but is not limited to the provision of direct psychosocial interventions (i.e., non-pharmacological interventions), such as mental health therapy, couple and family counselling, psychotherapy and psychosocial interventions designed to improve, enhance, maintain socio-emotional, psychological, behavioural, interpersonal functioning and/or reduce risk factors, such as psychiatric symptoms and/or addictions. Despite the culture of evidence-based practices in mental health settings, the practice of supervision of mental health professionals lags behind in its use of evidence-informed practices (Schoenwald et al., 2009). Further exacerbating the problem is that most supervisors assume, perhaps erroneously, that the supervision they provide is effective (Kilminster & Jolly, 2000). There are at least three clinical reasons (Milne, 2009) to develop a better understanding of supervision: one, effective supervision may be essential to enhance and maintain mental health professionals’ competencies; two, supervision can increase fidelity to evidence-based treatment models; and third, effective supervision can reduce unnecessary interventions (e.g., mental health professionals making referrals to multiple services when contraindicated or failing to disengage services when goals are achieved) and reduce waitlist times and health care costs. Although the quality of the evidence emerging from outcome research on the effectiveness of supervision is limited (Schoenwald, Sheidow, & Chapman, 2009; Waller, 2009) due to methodological issues, there is indication that supervision results in improved patient care outcomes (Bambling, King, Raue, Schweitzer, & Lambert, 2006; Bradshaw, Butterworth, & Mairs, 2007; Callahan, Almstrom, Swift, Borja, & Heath, 2009; Milne, Aylott, Fitzpatrick, & Ellis, 2008; Watkins, 2011) and that it acts as a quality assurance mechanism (Schoenwald et al., 2009). Without supervision, the quality control of mental health work depends on the ability of mental health professionals to self-evaluate their competencies (Hansen et al., 2006). Self-evaluations prove to be difficult with early career and lower skilled clinicians who are found to typically over-rate their competencies (Vallance, 2005), which can have negative implications for patient outcomes and safety. Clinical supervision is an ongoing supportive learning process for clinicians of all levels to develop, enhance, monitor, and, when necessary, remediate, professional functioning (Bernard & Goodyear, 2014). Supervision is a distinct professional practice with knowledge, skills, and attitudes components. For some professions (e.g. Marriage and Family Therapy), supervisors require specific training to be recognised as an “approved supervisor” while other professions promote experienced clinicians into the role of “supervisor” after some time and clinical experience (Falender, Burnes, & Ellis; 2013; Falender, Ellis, & Burnes, 2013; Bernard & Goodyear, 2014; Reiser & Milne, 2012). The chief function of supervision is to minimize non-purposeful activity and maximize intentionality with the goal of directly optimizing clinician competencies, ensuring quality control, and enhancing confidence for the end goal of improving patient outcomes (Milne, 2009). Supervision is provided in a variety of formats including one-on-one supervision, small group supervision, peer-based consultation, and facilitated team-based consultation. Supervision can include presentations via case discussion, video review or live presentation/demonstrations (Todd & Storm, 2002). There are a number of definitions of supervision put forth by the various mental health professions. For example, the American Psychological Association (2014) defines supervision as: … a distinct professional practice employing a collaborative relationship that has both facilitative and evaluative components, that extends over time, which has the goals of enhancing the professional competence and science-informed practice of the supervisee, monitoring the quality of services provided, protecting the public, and providing a gate keeping function for entry into the profession. (p. 5) The Association for Counsellor Education and Supervision (2011) provide a list of guidelines in twelve areas for addressing the ethical and legal protection of the rights of supervisors, supervisees, and clients; and meeting the professional development needs of supervisees while protecting client welfare. While the Council for Accreditation of Counseling and Related Educational Programs (2009) offer a definition of supervision in an educational setting as: A tutorial and mentoring form of instruction in which a supervisor monitors the student's activities in practicum and internship, and facilitates the associated learning and skill development experiences. The supervisor monitors and evaluates the clinical work of the student while monitoring the quality of services offered to clients. (p. 62) Further definitions are offered by the American Association for Marriage and Family Therapy (AAMFT), the National Association of Social Work (NASW), the British Association of Counselling and Psychotherapy (BACP), and the Royal Australian and New Zealand College of Psychiatrists (RANZCP). AAMFT (2014) describe the process of supervising marriage and family therapists (MFT) as: …evaluating, training, and providing oversight to trainees using relational or systemic approaches for the purpose of helping them attain systemic clinical skills. Supervision is provided to an MFT or MFT trainee through live observation, face-to-face contact, or visual/audio technology-assisted means. (p. 5) Another definition of supervision is offered from the NASW (2013). This organisation defines professional supervision as: the relationship between supervisor and supervisee in which the responsibility and accountability for the development of competence, demeanor, and ethical practice take place. The supervisor is responsible for providing direction to the supervisee, who applies social work theory, standardized knowledge, skills, competency, and applicable ethical content in the practice setting. The supervisor and the supervisee both share responsibility for carrying out their role in this collaborative process. (p. 6) The BACP (2016) defines supervision as a “formal arrangement for therapists to discuss their work regularly with someone external in order to maintain adequate standards of therapy”. The BACP recommends that supervisors not know the identity of clients and be members of a recognized professional body and preferably accredited. A final definition of supervision is offered by the RANZCP (2012) that outlines an apprenticeship process that includes a minimum of four hours per week for 40 weeks of supervision by a College-accredited supervisor. The RANZCP define supervisors as clinically competent in the area they are supervising in and familiar with the use of a competency-based assessment tool. Each of the definitions developed by the different professional organisations share developmental, ethical, and supportive roles while each offer different emphases based on the epistemological roots of their professions and understandings of supervisory relationships. There are also different approaches to defining the intervention of clinical supervision. Milne (2007), for example, proposed four criteria for developing a definition of supervision. The first criterion is precision which can be accomplished by clarifying what is distinct about supervision and also in comparison with what it is not (e.g. not therapy). Secondly, a definition of supervision must include specification. This will include the elements that make up supervision (e.g. video review). The third criterion proposed by Milne is that of operationalization which he suggests must be stated in the form that permits measurement. The fourth and final criterion is corroboration which can be substantiated with adequate support from the research. There are a number of challenges for this research to applying all four of these criteria for a single definition of clinical supervision or to promote as Milne (2007) suggests an “empirical” definition of clinical supervision. One challenge is the varied understanding of supervision across the mental health professions. Psychology is the only mental health profession that explicitly adheres to a science-practitioner model (Frank, 1984) and places an emphasis on what is measurable by the senses. While each profession engages in evidence-based practices there is a richer dialogue of what constitutes evidence among the different professions as well as a critique of the narrow band of empiricism that drives the science-practitioner approach (e.g. Coulter, 2011; Elliott, 1998; Gambrill, 2010; Holmes, Murray, Perron, & Rail, 2006; Slife, Wiggins, & Graham, 2005; Staller, 2006; Wendt, Jr., 2006). To be systematic, it is important that we review research from across the mental health professions. For the purpose of this systematic review we will include research that defines supervision as involving a supportive learning process for clinicians when carrying out psychotherapy, counselling and/or the provision of psychosocial mental health interventions of all levels to develop, enhance, monitor, and when necessary, remediate, professional functioning. We will include research where the supervision sessions may have: case-presentations, presentation of video or audio-tapes from a therapy session, exploration of self-of-the-therapist issues, or process recordings (interpersonal process recall). And the supervision can take place: one-to-one, triadic (1 supervisor and dyad), in a group format, live (with call-in and/or with bug in ear), consultation teams, reflecting teams, or online. One of the objectives of this review is to assess the research about supervision of multicultural competencies. A further clarification is required to address the understanding of multicultural competencies. Developing multicultural competence is integral to the formation of clinical competence (Falender, Shafranske, & Falicov, 2014). Multicultural competencies in the mental health professions include a range of attitudes, beliefs, knowledge, skills, and actions (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015) that provide a framework to optimize client engagement, participation and benefit from psychotherapeutic intervention and research. Developmental domains of multicultural competencies include mental health professional self-awareness, the client's worldview, the therapeutic relationship, and mental health and advocacy interventions (Ratts et al., 2015). There are a number of obstacles to integrating cultural perspectives in supervision including the need to clarify the role of understanding what cultural heritage and sociopolitical context have to do with human suffering and critically examining the epistemological foundations of the psychotherapies that are used (Falicov, 2014). Multicultural competence is considered an ethical and practice imperative and there is a need to clarify the best research-based approaches to the supervision of mental health professionals in this area (Falender, Shafranske, & Falicov, 2014). The aim of this part of the systematic review is to identify the research pertaining to the supervision of multicultural competencies in the mental health therapies. This will not include training or workshops about multicultural competencies. The logic model for this intervention outlines a series of themes as opposed to a singular intervention, as clinical supervision takes many forms and can be informed by a myriad of models ranging from behavioral to psychodynamic approaches (often mirroring mental health intervention approaches). There is, however, a shared objective for supervision across professions to minimize non-purposeful activity and maximize intentionality with the goal of directly optimizing clinician competencies, ensuring quality control, and enhancing confidence for the end goal of optimizing care (Milne, 2009). Supervisors accomplish one or more of these objectives by targeting supervisee knowledge, skills, attitudes and/or behaviours. Educational settings responsible for supervising mental health trainees/students share the duties as outlined by Council for Accreditation of Counseling and Related Educational Programs (2009). These supervision interventions include atutorial and mentoring form of instruction in which a supervisor monitors the student's activities and facilitates the associated learning and skill development experiences. The measurement of this form of supervision happens with direct verbal feedback, grading, and feedback forms. Also important to consider when discussing supervision interventions is the clinical approach such as family or systemic therapy. For systemically oriented supervisors and mental health professionals, the self is unavoidably a part of the therapeutic system (Cheon & Murphy, 2007; Lee & Everett, 2004). Integrating the self into the therapeutic system and supervision generates self-of-the-therapist issues that are to be explored in supervision (Aponte et al., 2009). One of the purposes of this self-exploration is to to learn how to use these emotional materials to enhance the effectiveness of the professional use-of-self (Timm & Blow, 1999). Aponte et al. (2009) report that the degree to which mental health therapists commit to exploring the challenges in their lives and engage in personal growth and development is proportionate to the ability to relate to clients’ efforts to deal with their challenges. Progress in supervision is measured by supervisees’ reflective journaling, review of video of therapy sessions, and exploration of challenges in group and individual supervision. Assessment of the supervision is through supervisee self-reports and review of clinical work by supervisors. The intervention of supervision includes knowledge, skill, attitude, and/or behavioural components and the priority placed on each will vary across supervision approaches for reasons previously noted. Moreover, supervision of mental health professionals can vary according to the: supervisor, therapeutic approach, clinical setting, mental health worker, resources available to support supervision, access to supervisors, profession, as well as other factors. The means by which supervision is evaluated varies from experimental designs to qualitative approaches. Experimental and quasi-experimental designs typically employ quantitative measures, compared before and after supervision and with comparison groups in order to determine whether supervision is effecting improvements on the supervisee's skills and/or knowledge, as well as on clinical outcomes with the supervisee's clientele. Qualitative methods are often harnessed to help illuminate the experiences and perspectives supervisees and/or supervisors have with the supervision process as well as help identify the key facets of the supervision mechanism. There are no systematic reviews on this topic registered with the Campbell Collaboration or the Cochrane Collaboration to date. However, a number of previous reviews have addressed clinical supervision, but have been somewhat restricted and have not looked at it from an overall mental health professional perspective. For example, Bogo and McKnight (2006) published a review of the research and non-research literature pertaining to clinical supervision within the field of social work and social work trainee field education. Due to the broad scope of practice of social workers Bogo and McKnight did not focus on the practice of mental health therapy by social workers or the supervision of this practice. A systematic review of social work supervision practices specific to the field of child welfare was conducted by Carpenter, Webb and Bostock (2013), however their scope did not include mental health therapies. Brunero and Stein-Parbury (2008), Francke and Graaff (2012), Butterworth, Bell, Jackson, and Pajnkihar (2007), as well as Cummins (2008) also conducted reviews of the literature examining the effectiveness of clinical supervision for nurses. The focus of the reviews included a broad range of nursing interventions and included few studies pertaining to nursing supervision specific to the practice of mental health therapy. Dawson, Phillips and Leggat (2013) broadened the population of their review to include all allied health professions, however, similarly they did not focus on mental health therapy. Faman and colleagues (2012) completed a systematic review of outcomes of supervision on patient care and medical residents’ competencies. Although this review included a targeted population for psychiatry, this study did not search for, or identify studies specific to supervision for mental health therapies. Other reviews of studies within the field of medicine, such as those by Kilminster and Jolly (2000) identified key mechanisms of supervision leading to positive outcomes including the nature of the supervisory relationship. Other reviews looking at allied health professionals (Barak, Travis, Pyun, & Xie, 2009) focused on positive outcomes for supervision arising through the supervision process including enhanced job satisfaction and reduced burnout. Follow-up reviews are needed as these reviews did not specifically examine supervision pertaining to mental health therapy. A review conducted by Milne and James (2000) did focus on supervision for mental health therapy, however, mental health therapy was narrowly defined as cognitive behavioural therapy (CBT). This review is important for a number of reasons. First, little is known about what evidence exists for supporting the use of supervision or what supervision practices may be help/harmful for supervisees, which ultimately impacts the level of care received by patients accessing mental health services (Wheeler & Richards, 2007). Second, little is known about the evidence for multicultural and/or culturally sensitive supervision practices and how these may impact supervisee competence and patient care (Falendar et al., 2014). Third, there is indication in the research literature that competent supervision results in improved patient care outcomes and that it acts as a quality assurance mechanism (Tracey, Wampold, Lichtenberg, & Goodyear, 2014; Watkins, 2012). Without supervision, the quality control of mental health interventions depends on the ability of mental health therapists to self-evaluate their competencies. Self-evaluations prove to be difficult with early career and lower skilled therapists who are found to typically over-rate their competencies, which can have negative implications for patient outcomes and safety. Finally, supervision is considered an essential component of modern effective health care systems and health care training programs in general (Kilminster & Jolly, 2000). This systematic review will contribute to enhancing our knowledge of effective supervision practices, including the impact of multicultural supervision, which will lead to improved care, better training, and better management of care. The secondary objectives of this review include: Identifying the key experiences of supervisees and/or supervisors with the supervision process that help identify any reasons why clinical supervision may succeed or fail in improving clinical and/or multicultural competencies in mental health professionals and/or succeed or fail in improving health outcomes for patient/clients participating in mental health therapy. This review will include experimental (i.e., Randomized controlled trials: RCTs) and parallel cohort quasi-experimental designs (QED) if the treatment and control groups were assessed at the same points in time and matching or statistical controls have been employed to ensure no significant baseline differences between these groups in relation to key constructs (i.e., supervisee competence in mental health therapy/interventions, multicultural competency, nature of the supervisory relationship). Studies will be included that have a control group that include either peer-based consultation or no supervision condition. We will include QEDs due to the likelihood that most evaluations of supervision for mental health professionals will be conducted in real world, naturalistic settings that reduce the feasibility of RCTs. All studies formally included in the review must evaluate the effectiveness of clinical supervision on at least one of the outcomes listed in the subsequent section. In relation to the secondary objective of this review we will also review non-experimental studies. In our preliminary review of the state of the research landscape pertaining to clinical supervision, qualitative studies reveal that many studies relevant to our focus employ diverse methodologies (i.e., single-subject designs, cohort/longitudinal studies, case control and qualitative studies). Therefore, in order to gain insight into reasons why supervision may succeed or fail to enhance clinical and multicultural competencies of mental health professionals and/or health outcomes of patients, we will report findings from these studies in a tabular format and narrative summary that will provide a fuller context to our findings regarding our analysis of the RCTs and QEDs formally included in our review. Similarly, findings from relevant previously conducted review articles and/or meta-analyses will not be formally included in our review or analyses, but will be reported in the form of a narrative summary within our review. Review articles and meta-analyses identified in our literature search will also serve as a means of identifying any additional studies not previously identified within our search. The participants to be included in this review must be in a professional, structured supervisory relationship either as a supervisee or supervisor, or as a student in practicum, internship, or residency, whereby the supervisor is identified as having a formal role and responsibility for the supervision process. This supervision must also be in relation to the provision of mental health therapy. Peer supervision (i.e., supervision provided without a formal mandate/scope of practice between two or more individuals practicing in a same or similar role, typically that of psychotherapist) will only be included in this review as a control condition. Types of mental health professionals included in this review are psychotherapists, psychologists, counsellors, couple/marital and family therapists, social workers, psychiatrists, nurses, pastoral counsellors, and trainees in each of these professions. This review will include studies examining clearly specified clinical supervision models intended to minimize non-purposeful activity and maximize intentionality with the goal of directly optimizing mental health therapists’ competencies (i.e., knowledge, skill, attitude &clinical behaviour) and client outcomes, ensuring quality control, and/or enhancing confidence for the end goal of optimizing care. The intervention may be delivered to a range of mental health therapists in a variety of formats including: one-to-one, triadic (1 supervisor and supervisee dyad), in a group format, live (with call-in and/or with bug in ear), consultation teams, reflecting teams, or online. Supervision will be demarcated from theoretical-based training in models of mental health therapy. Research will be included that examines supervision in relation to a supervisee's application of mental health therapy to a specific patient/client(s) situation and/or the supervisory discourse will pertain to a unique patient/client situation. Research will be excluded that is not directly focused on investigating the supervision process as it pertains to the needs of unique patients/clients, but instead focus only on the training of individuals related to the acquisition of a theoretical understanding of a mental health model and/or the acquisition of general knowledge and/or general skills related to mental health therapy without the application of this model to specific patient(s)/client(s) situations. Research studies examining competency development using simulated-patients/clients will be included in the present review, but will be treated as a distinct sub-group for analytic purposes. The primary outcome(s) for this study will include the measurement of effectiveness of competencies (i.e., knowledge, skills, attitudes and clinical behaviours) in the provision of mental health therapy, including multicultural competencies. We are also interested in outcomes pertaining to the effectiveness of the supervisory relationship/process and client outcomes. Examples of these measures are included below. Additional relevant and validated measures identified through the review of study will also be considered. We will also examine the effectiveness of supervision for mental health therapy related to patient/clinical care outcomes. Possible measures to be included are listed below. Additional relevant measures identified through the review of study will also be considered. The duration of follow up may vary due to the nature of the different types of supervision provided, and the limitations of the studies. A portion of the studies are likely to include supervision that is time limited, such as graduate program internship, practicum and/or residency supervision. Others may include clinical and professional supervision that are likely an on-going experience throughout a helping professional's career. The follow up duration for this study will be inclusive of all of these supervisory experiences. There will be no restriction placed on the inclusion of articles based on the duration of the intervention and/or the duration of the follow-up measurement pertaining to study outcomes. This proposed review will include studies of supervision conducted in settings that employ or train mental health professionals engaged in the practice of mental health therapy. Settings will include universities/colleges, child welfare services, psychiatry institutions, training programs, web-based programs, hospitals, counselling agencies, and physicians’ offices. The review will include the following experiences: residencies/internships/practicums, student supervision, and clinical supervision across mental health professions. We will exclude studies of educational curriculum of supervision and workshops. We will perform electronic searches of bibliographic databases, as well as on open web-sites and in the grey literature. We will also search for on-going studies. We will have no publication date, geographic, or language restrictions. Media and software reviews will not be included. The following sources will be searched: Ovid PsycINFO Ovid MEDLINE CINAHL Social Work abstracts EMBASE (Embase.com) Web of Science Social Services abstracts Educational Resources Information Centre (ERIC) PubMed EBSCO ACADEMIC JSTOR SAGE Science Direct Springer Wiley Applied Social Sciences Index and Abstracts (ASSIA) Cochrane Library Campbell Library Google Scholar Theses and Dissertations (Proquest) The search strategy is comprised of 3 main concept categories: supervision, profession, methodology, and for the objective of addressing multicultural competencies we will add a 4th category, culture. Within each category there are textword (“free text”) terms and, where appropriate, subject headings in indexed databases. We will approach the search from broad-to-narrow in order to capture general studies on clinical supervision, while narrowing the broad search to focus on studies related to multicultural competencies. The following is one example of the search strategy in OVID PsycINFO: ((evidence adj based) OR (random* adj assign*) OR (random* adj control*) OR (random* adj control* adj trial*) OR (evaluat* adj study) OR (evaluat* adj studies) OR RCT OR (quasi adjexperimen*) OR (case adj study) OR (case adj studies) OR (case adj control) OR (qualitative adj studies) OR (qualitative adj study) OR (qualitative adj analysis) OR (content adj analysis) OR (participat* adj observation*) OR (focus adj group*) OR (systematic adj review*) OR (meta adj analysis) OR (mixed adjmetaanal*) OR review* OR metasynth* OR meta-synth* OR interview* OR case-study OR case-studies).ab, ti,id. OR Qualitative research/ OR Methodology/ OR Quantitative Methods/OR Quasi Experimental methods/ OR Empirical Methods/ OR Evidence based practice/ A hand search will also be conducted on key journals within the last year to ensure early on-line publications not yet indexed are identified related to supervision and psychotherapy including: The Clinical Supervisor, Counselor Education and Supervision, Social Work Supervision, and Journal of Therapy, Consultation and Training. A search of the online table of contents of each of these journals over the last two-year period will be conducted in the event that relevant articles have not been indexed into searched databases. Hopewell et al. (2002)