This document discusses frameworks and models for clinical supervision in healthcare. It describes Proctor's 1987 model of normative, restorative, and formative supervision. Heron's 1989 model includes authoritative and facilitative supervision interventions. Powell's 1993 model includes administrative, evaluative, clinical and supportive components. The document also discusses evidence that effective supervision improves patient outcomes, is most impactful for less experienced trainees, and depends most on the quality of the supervisor-supervisee relationship. Characteristics of effective supervisors include being empathetic, supportive, flexible and focused, while ineffective supervisors are rigid, lack empathy and support, and emphasize weaknesses.

1. Perspectives about and
Models for Supervision in the
Health Professions
Violet H. Barkauskas, PhD, RN, MPH, FAAN
The University of Michigan

2. Focus of the Presentation
 The context of health care
 Frameworks for supervision in health
care
 Examples of framework application
 Evidence of effectiveness

3. Context of Health Care - Western
 Hierarchical system of oversight
 Clinical supervision is a major
emphasis because of:
 Concern for patients
 Current re-emphases on patient safety
 Reimbursement & certification regulations
 Concerns about litigation

4. Common Examples
 Training & education – students in all
professional discipline
 Professional development requirements
 Oversight of assistant/ancillary
personnel
 Common (almost ubiquitous) in most
settings, especially for nursing
 Examples – nursing assistants in hospitals
& nursing homes, home health aides,
community health workers

5. Proctor’s Model of Supervision (1987)
 Normative – Administration & Quality Assurance
 Manage projects
 Ensure patient safety
 Assess & assure quality
 Improve practice
 Restorative – Support & Assistance with Coping
 Identify solutions to problems in practice
 Alleviate stress
 Formative – Education & Professional Development
 Skills & knowledge

6. Applications of the Model
 Normative (management, safety, assurance)
 Meetings
 Observation of care
 Formal evaluation
 Telephone consultation
 Documentation in hard & electronic media
 Patient records
 Activity logs
 Restorative (support & assistance with coping)
 Group supervision
 Case conferences
 Identification of solutions to problems in practice
 Formative (education & professional development)
 Continuing education

7. Heron’s Model of Supervision (1989)
 Authoritative Supervision Interventions
 Prescriptive – direct behavior
 Informative – give information/instruct
 Confronting – challenge
 Facilitative Supervision Interventions
 Cathartic – release tension/strong emotion
 Catalytic – encourage self-exploration
 Supportive – validate/confirm

8. Powell’s Model of Supervision (1993)
 Components
 Administrative
 Evaluative
 Clinical
 Supportive
 Conceptualization of supervisor as a servant leader who
 Is self-aware
 Operates with focus & energy
 Is proficient in many aspects of the job
 Makes the organizations mission & vision clear by standing ahead
of the followers while standing behind their actions
 Shares power
 Values people by caring for them

9. Assumptions of Powell’s Model of
Clinical Supervision (Powell, 1993)
 People have the ability to bring about change in their
lives with the assistance of a guide.
 People do not always know what is best for them as
they may be blinded by their resistance to & denial
of the issues.
 The key to growth is to blend insight & behavioral
change in the right amounts at the appropriate time.
 Change is constant & inevitable.
 In supervision, as in therapy, the guide concentrates
on what is changeable.
 It is not necessary to know about the cause or
function of a manifest problem to resolve it.
 There are many correct ways to view the world.

10. Structure of Supervision
 Individual – 1 to 1
 1 supervisor & 1 supervisee
 Group
 1 supervisor with 4-6 supervisees
 Triad – 1 supervisor & 2 supervisees
 Team – colleagues working together outside the
group
 Network – people not usually working together
outside the group
 Administrative Arrangements
 Hierarchical
 Non-hierarchical

11. Supervision Venues
 Routine interactions on the job
 Informally
 In scheduled meetings
 Indirectly – e.g., by talking to patients
 Through remote communication
 Telephone
 Computer
 Written documentation, e.g., logs, records,
reports

12. Current Supervision Debates
 Qualifications of the supervisors
 From the same discipline
 A different discipline
 A peer colleague
 Expertise
 Content of care
 Processes of development
 Guided reflection vs. more traditional clinical
supervision
 Collaborative supervision
 May not challenge each other sufficiently (Walsh
et al., 2003)

13. Evidence - Supervision Effectiveness
(Kilminster & Jolly, 2000, p. 833)
 Supervision has a positive effect on patient
outcome & lack of supervision is harmful to
patients.
 Supervision has more effect when the
trainee is less experienced.
 Self-supervision is not effective.
 The quality of the relationship between
supervisor & supervisee is probably the
single most important factor for effective
supervision.
 Behavioral changes can occur quickly –
changes in thinking & attitude take longer.

14. Tips
 Combine supervision with focused
feedback
 Continuity
 Reflection by both participants

15. Characteristics of Effective
Supervisors
 Empathetic
 Supportive
 Flexible
 Interested in supervision
 Track supervisees effectively
 Link theory with practice
 Engage in joint problem-solving
 Interpretative
 Respectful
 Focused
 Practical
 Knowledgeable

16. Characteristics of Ineffective
Supervisors
 Rigid
 Low empathy
 Low support
 Failure to consistently track supervisee concerns
 Failure to teach or instruct
 Indirect & intolerant
 Closed
 Lack respect for differences
 Non-collegial
 Lacking in praise & encouragement
 Sexist
 Emphasize evaluation, weaknesses, & deficiencies

17. Recommended Content for
Supervisor Training
 Supervision frameworks
 Assessment of learning needs
 Teaching the adult learner
 Counseling
 Provision of feedback
 Issues of power & social stratification
 Transcultural relationships

18. References
 Heron, J. (1989). Six category intervention analysis. Guildford:
Human Potential Resource Group, University of Surrey.
 Kilminster, S. M., & Jolly, B.C. (2000). Effective supervision in
clinical practice settings: A literature review. Medical Education,
34, 827-840.
 Powell, D. (1993). Clinical supervision in alcohol and drug abuse
counseling. San Francisco: Jossey-Bass .
 Proctor, B. (1987). Supervision: A cooperative exercise in
accountability. In M. Marken, & M. Payne (Eds.). Enabling and
ensuring supervision in practice. Leicester: Youth Bureau and
Council for Education and Training in Youth and Community
Work.
 Sloan, G., & Watson, H. (2002). Clinical supervision models for
nursing: Structure, research and limitations. Nursing Standard,
17(4), 41-46.
 Walsh, K. et al. (2003). Development of a group model of clinical
supervision to meet the needs of a community mental health
nursing team. International Journal of Nursing Practice, 9, 33-39.

19. QUESTIONS?