Supporting Non-Clinical Staff through the Use of Clinical Supervision

Abstract

Clinical supervision is a commitment from supervisors to ensure the provision of quality services and nurture the professional growth of supervisees. Clinical supervision is made up of formative, normative, and restorative domains. While supervisors naturally focus on administrative and formative domains of clinical supervision, there needs to be a shift to focus more on clinical supervision’s restorative (self-related/self-care) domain. Given the workforce crisis, the unrest in the U.S., and post-pandemic residues, organizations must formalize clinical supervision to attend to their workforce. The study to assess the effectiveness of clinical supervision among non-licensed care coordinator, findings affirmed best clinical practices in the administrative and formative domains, while clinical supervision covering the restorative domain pointed to practices that were not deemed effective. Both care coordinators’ and supervisors’ views aligned on experiencing clinical supervision that did not prioritized discussions of “self” in supervision. Effective clinical supervision must equally focus on discussion in the three domains of clinical supervision, and supervisors must be equipped with the right tools to adopt the best clinical supervision practices. Crisis-based clinical supervision is one of the models supervisors can apply through the Just Practice framework to lean in more on the restorative domain of clinical supervision for non-licensed staff.

1. Introduction

Before the COVID-19 pandemic, the United States struggled with the discord between high healthcare costs and poor health outcomes for people with behavioral needs. Social and economic conditions, workforce shortages, physical environment challenges, and healthcare system barriers are the main culprits of poor health outcomes in the United States [1]. The shortage of behavioral staff, burnout, and compassion fatigue are some of the residues of the pandemic and present a threat to achieving the triple aim, which goal is to offer better healthcare experience and health outcomes and decrease the per capita cost of Care for people with chronic behavioral health needs [2]. Data reported in June 2020 showed that over half of the adults in America reported having unhealthy sleep hygiene, experiencing deteriorating chronic conditions, increased substance misuse, and suicide risks because of the COVID-19 pandemic [3]. Consequently, we face the reality of managing an increased and acute behavioral population mental health with a scarce and fatigued workforce. Continued attention to workforce development and readiness is critical for stabilizing the behavioral health subset of the U.S. adult population. The acknowledgment of the crucial role of the workforce in achieving the triple aim bore the fourth aim, which concentrates on improving the work-life of physicians, clinicians, and staff [4]. Clinical supervision has often been advanced as an effective intervention to support clinical staff in their role. What happens to non-licensed behavioral health staff who are not considered clinicians but work in the behavioral setting? This subset of the workforce is the front line and the largest group of behavioral health professionals, and they should be offered clinical supervision to better equip and support them in their role.

The following pages will explore delivering clinical supervision to non-licensed staff. The sections will describe the role and professional needs of the non-licensed workforce, define and discuss the three domains of clinical supervision, summarize the methodology and findings of the study, and provide recommendations for a clinical supervision model to support non-licensed staff in the behavioral health arena effectively. Specifically, we will explore the crisis-based clinical supervision model and the just practice framework to illustrate supporting non-licensed staff.

2. Clinical supervision for non-licensed workforce

2.1 Non-licensed workforce in behavioral healthcare

In behavioral healthcare, licensed staff operate as clinicians, and non-licensed staff work as care coordinators, case managers, patient navigators, etc. Their scope of work includes identifying treatment providers in the community, establishing connections to care, outreaching, arranging/brokering transportation to and from appointments, assisting with social service needs (benefits, housing, etc.), participating in hospitalization discharge planning, as well as keeping accurate documentation in the electronic health record. Non-licensed staff are essential in getting service users to clinicians to receive the necessary treatment. Non-licensed staff often engage service users who are not in the best mental health state and/or are disconnected from Care. The role requires a high level of engagement with the patient, an understanding of mental health needs, and an awareness of the staff’s needs. It is necessary to broaden the definition of clinical work and not limit it to only diagnosing, assessing, and treating. We should consider including the engagement work as preliminary clinical work preparing service recipients to enter Care. Staff needs to be knowledgeable about primary mental health signs, determine the best way to build trust and rapport, decide when to discuss treatment options, make a referral, be a listening ear, or escalate to 911. Non-clinical staff are not only ill-prepared for their task, but they also do not receive clinical supervision despite experiencing some of the same stressors clinicians experience when dealing with service users. Case managers have admitted their lack of skills [5] in managing the job responsibilities. Ironically, clinicians equipped for their role receive continued support via clinical supervision, while the ill-equipped workforce receives the least structured support. It is time to shift our views of the work of non-clinical staff in behavioral health and commit to providing them with the clinical supervision licensed clinicians receive.

2.2 What is clinical supervision?

Clinical supervision (C.S.) is a continuous supportive learning process for clinicians at different career stages to help them function optimally in their duties [6]. The National Association of Social Workers also defines clinical supervision as establishing a co-learning alliance between a supervisor and a supervisee to promote the development of skills, knowledge, attitudes, and ethical standards in clinical practices [7]. Falender et al. [8] emphasized that “the effectiveness of supervision encompasses not only changes in the client outcomes but also changes in therapist’s competencies (e.g., in session skills and professionalism” (p.14). Further, there is an apparent advantage to using clinical supervision to ease supervision for supervisees through experiential learning and promote evidence-based positive clinical outcomes [9]. Regardless of the clinical supervision model supervisors use, all three domains recommended in Proctor’s model of clinical supervision and discussed by Kadushin and Harkness [10] should be discussed. Those domains are normative/administrative, formative/educational), and restorative/supportive.

Normative/administrative supervision involves bringing staff on board, determining their workload, evaluating performance, etc. In this role, the supervisor operates in the capacity of a manager. This domain emphasizes understanding clients’ rights, standards, professional ethics, and casework management [11]. The subdomains under the normative domain are “Importance/Value of Clinical Supervision (IMV)” and “Finding time (F.T.)” [12].

Formative/educational supervision entails educating, training, sharing experiences, promoting professional growth, and helping subordinates solve problems related to their cases. The supervisor’s role is equivalent to that of the teacher. Similarly, Proctor [11] and Kadushin and Harkness [9] advanced skills such as teaching, facilitating, training, sharing experiences, and personal integration as formative or educational tasks. The subdomains under the formative domain are “Improve Care/skill (IMP)” and “Reflection (REF)” [12].

Restorative/supportive supervision encompasses the supervisor playing a role similar to that of a counselor. The supervisor must help the supervisee manage job-related stress, which directly influences people’s decision to leave the workplace [11]. Haarman [13] noted that adequate supervision should not be limited to reviewing notes and approving forms and reports; it should aim to foster mutuality, workers’ rights, appraising, and self-monitoring [10, 11]. The subdomains under the restorative domains are “Trust/Support (T.S.)” and “Support advice/Support (SAS)” [12].

Studies have affirmed that the few advantageous aspects of supervision can be seen in the supervisory relationship, and those tend to yield the most beneficial outcomes for supervisees and clients [14, 15]. Yet, supervision literature still highlights the scarcity of training, lack of mentors, and inadequate organizational structure as roadblocks to implementing clinical supervision in social service organizations [16, 17, 18].

2.3 Methodology

This research study inspected the perceptions of care coordinators and care coordinators’ supervisors of the effectiveness of clinical supervision in care coordination within the Heath Homes context in New York State. It examined the alignment of the perceptions of care coordinators and care coordinators’ supervisors within each domain of clinical supervision. The study also evaluated if current clinical supervision practices mirror best practices of effective clinical supervision. A Care Coordinator, as defined by The New York State Department of Health, is a staff member with a bachelor’s degree and two years of experience supporting people with behavioral health needs. On the other hand, a supervisor is defined as a master’s level clinician with experience supervising staff working directly with people with behavioral health needs. Participants in this study did not have any clinical licenses like the norm group used by Winstanley and White to set the standard scores for Allied health staff.

Participants responded to a two-part survey using an anonymous survey-based approach. The first part of the survey consisted of Manchester Clinical Supervisor Scale-26 questions using a Likert-like scale to describe respondents’ experiences of clinical supervision within the three domains of clinical supervision. The MCSS-26 solely captures a supervisee’s perception, in this case, the care coordinator’s. However, in this study, care coordinators’ supervisors answered the MCSS-26 questions as supervisors by referring to themselves as the supervision providers. It needs to be noted since the study occurred during the COVID-19 pandemic, a second part of the survey was added to include questions about clinical supervision sessions before and during the COVID-19 pandemic. The following were the research questions:

1. RQ1: Is the clinical supervision provided to care coordinators perceived as effective by care coordinators?

2. RQ2: Is the clinical supervision provided to care coordinators perceived as effective by care coordinators’ supervisors?

3. RQ3: Is there alignment between perceptions of a care coordinator and a care coordinator supervisor of the effectiveness of clinical supervision as measured by the six subscales (value of C.S., finding time for C.S., trust, and support of C.S., support and advice of C.S., improve skills/care of C.S. and reflective of C.S.)?

4. RQ4: To what extent has COVID-19 impacted the clinical supervision received by care coordinators?

5. RQ5: To what extent has COVID-19 impacted the clinical supervision provided by care coordinators’ supervisors?

6. RQ6: What are the perceptions of care coordinators and care coordinators supervisors on the effectiveness of providing care coordination remotely during this COVID-19 pandemic?

7. RQ7: Do current practices of clinician supervision in the health home mirror best practices of clinical supervision?

The study’s participant target population was a range of 100–300 care coordinators and a range of 30–75 care coordinators’ supervisors. This researcher elected to use a purposive sample and projected that a sample of 30 participants in each category would permit preliminary exploration of the clinical supervision phenomenon in human services. Care coordinators and care coordinators’ supervisors self-selected to participate in the study. The study secured a license to gather up to 100 surveys and got 68 responses without missing information. Care coordinators completed 35 surveys, and Care coordinators’ supervisors completed 33 surveys. The researcher used Qualtrics to collect the data and preserved the anonymity of all study participants by preventing the sharing of information such as I.P. or e-mail address. IBM’s Statistical Package for Social Sciences tool (SPSS) for analysis was used to input the survey data. Upon completing the survey, the researcher used descriptive statistics, the chi-square test of independence, and a series of t-tests to analyze the data and answer all identified research questions.

As required by the MCSS-26, the researcher gathered the following: gender, frequency of clinical supervision sessions (every week, every two weeks, monthly, 2–3 months, over three months apart), place of clinical supervision (within the workplace, away for the workplace, both), type of clinical supervision sessions (one-to-one basis, group sessions, 1:1, group, triad) and length of clinical supervision sessions (< 15 mins; 15–30 mins; 31–45 mins; 46–60 mins, >60 mins).

2.4 Findings

The findings indicated that Care coordinators and Supervisors perceived the clinical supervision received as effective based on the overall respective mean scores (M = 84.6; M 93.4). With the MCSS-26, the effectiveness of clinical supervision is represented by an overall mean score between 74 and 102.

Results of the study indicated that the mean scores of both Care Coordinators and Supervisors were higher than the norm group of allied health professionals (M = 74.7). The study’s result revealed that Care coordinators’ supervisors’ mean scores (M = 93.4) are higher than care coordinators’ (M = 74.7). A statistical difference of (p < 0.006) was noted in the overall mean scores of care coordinators and care coordinators’ supervisors. Therefore, the null hypothesis of alignment of the perceptions of care coordinators and care coordinators’ supervisors of the effectiveness of clinical supervision was not accepted. The survey also examined alignments between the Care coordinators and supervisors within the six sub-domains (Importance/Value of clinical supervision [IMV], Finding time [F.T.], Improve Care/skill [IMP], Reflection [REF], Trust/Support [T.S.]and Support advice/Support [SAS]). A statistical difference (p < 0.03) was noted in the supervisor advice/support subscale, hence rejecting the null hypothesis that there was an alignment of perceptions of the care coordinators and care coordinators’ supervisors in the SAS subscale. The data also revealed a statistical significance (p < 0.01) in the formative domain, therefore rejecting the null hypothesis of alignment of perceptions of care coordinators and care coordinators’ supervisors of clinical supervision in the formative domain. However, due to the lack of statistical significance in the normative domain and the trust/rapport subscale, the hypothesis of alignment in the perceptions of care coordinators and care coordinators’ supervisors in the normative domain and T.R. subscale was accepted.

The analysis for RQ4 consisted of two paired t-tests to compare care coordinators’ responses before and during COVID-19 on the frequency and duration of clinical supervision. Of the two paired-sample t-tests, the statistical significance (p > 0.019) was observed in the duration of clinical supervision; the data pointed to a decrease in the duration of clinical supervision during COVID-19. However, no statistical significance was noted in the frequency of clinical supervision (p < 0.726). The null hypothesis that COVID-19 did not impact the frequency and quality of clinical supervision was accepted due to the lack of statistical significance (p > .726, p > 0.290). Similarly, for RQ5, two paired t-tests were used to compare care coordinators’ supervisors’ responses before and during COVID-19 on the frequency, duration, and satisfaction with clinical supervision sessions. The two paired sample t-tests yielded a statistical significance (p < 0.022) in the duration of clinical supervision sessions. In contrast, no statistical significance was revealed in the frequency of clinical supervision (p > 0.666) and the satisfaction with clinical supervision provided (p > 0.148). The paired sample t-test with statistical significance (p < 0.022) permitted the null hypothesis that COVID-19 impacted the duration of clinical supervision sessions not to be accepted. Clinical supervision sessions duration decreased during COVID-19. The null hypothesis that COVID-19 did not impact the frequency of clinical supervision and satisfaction with clinical supervision was accepted due to the lack of statistical significance (p > .666; p > 0.148).

Although the study did not seek an alignment of the perceptions of care coordinators and care coordinators’ supervisors on the effectiveness of the provision of remote care coordination during COVID-19, it was interesting to look at the comparative responses. Overall, there was a lower percentage of care coordinators (37%) and Care coordinators’ supervisors (45%) who perceived the provision of remote care coordination as effective. Further findings revealed that 9% of care coordinators, compared to 6% of care coordinators’ supervisors, perceived remote care coordination as not effective.

Finally, the researcher used mean scores to determine if current practices of clinician supervision in the health home reflect best practices of clinical supervision. The mean scores in the restorative (36.1) and formative domains (25.0), trust rapport, supervisor advice/support (17.8), improved skills/care (14.2), and reflection (10.7) subscales pointed to the prevalence of best clinical supervision practices. However, the mean score of care coordinators in the normative domain (23.5) was lower than the norm group (24.1), which warrants further analysis. Care coordinators scored lower (13.1) than the norm group (15.1)in the importance/value (IMV) of clinical supervision but scored higher (10.4) on the finding time (FT) subscales compared to the norm group (8.4). The score on IVM attested that care coordinators did not see much value in clinical supervision sessions. The score on the FT subscale signals that care coordinators struggle to find time to engage in clinical supervision sessions.

Additional results showed that while clinical supervision practices in care coordination mirror best practices in the formative and restorative domains, only 22% of care coordinators reported receiving weekly supervision compared to 54% of the care coordinators who admitted to receiving monthly clinical supervision; 82% of care coordinators noted that clinical supervision sessions were between 30 to 60 minutes in length. The data indicated that clinical supervision was provided consistently and for the recommended duration. Related to the topic discussed in clinical supervision, care coordinators ranked patient care and documentation as 1st the 2nd most frequently covered topics in supervision. The primary goal of supervision is to prepare supervisees to offer Care to impact client outcomes effectively [8], and the study’s findings affirmed that client care remains the focus of clinical supervision sessions. On the contrary, current practices in clinical supervision in the restorative domain did not reflect the best practices of clinical supervision. Findings revealed that the topic of self-related was classified as the third or fourth topic discussed in supervision. Clinical supervision endorses that much more attention be given to the supervisee than to documentation.

Supportive/restorative supervision is vital in helping staff handle job-related stress and trauma in managing clients’ crises [10, 11]. Skills development is another discussion topic that fits under the category of self-related in the formative domain; clinical supervision sessions are intended to teach supervisees skills to improve client care. When topics around self-related are seldomly discussed, it may highlight that clinical supervision sessions are not focused enough on addressing staff competency and skills development. Findings indicated that discussion on the topic of self-related was rated as 3rd most frequently discussed topic in supervision by both care coordinators and care coordinators’ supervisors. This finding does not mirror best practices of clinical supervision, as existing literature notes that proper supervision does not only involve reviewing notes and approving forms and reports [13]. Supervisees view supervisors who show empathy, understand the importance of an honest relationship with the supervisee, and demonstrate a commitment to the supervision process as “best” supervisors [13]. Further, it is known that the degree to which the supervisee feels supported by the supervisor impacts the supervisee’s perceptions of effective supervision [12]. Discussions related to self should adequately help address supervisees’ needs and make them feel supported.

It is alarming to see that discussions around documentation were more frequent than discussions of self-related/self-care, such as managing job-related stress before the COVID-19 pandemic, and this pattern did not change during this COVID-19 pandemic. It behooves the community to propose a supervision model that provides a simplistic framework to help supervisors offer clinical supervision using a more balanced approach. The model discussed below was deduced from the study’s findings, which mirror a few current workforce challenges.

2.5 Worker-centered clinical supervision

Post the COVID-19 pandemic, the behavioral health workforce shortage is a crisis that organizations, government, academia, etc., are committed to solving. Staff recruitment and retention are among the most discussed topics in many workgroups. Incentive programs such as healthcare worker bonuses, loan repayment, training programs, or professionalization of non-clinical staff were proposed as solutions to attracting and retaining staff in the behavioral health sector. These incentives would not solve the crisis if not coupled with support to help the workforce feel equipped to manage the day-to-day stress of their job duties. Many clinical supervision models can be used to create a supportive and co-learning environment for staff. Based on the known residues of the post-pandemic and the birth fourth aim of attending to staff work-life [4], I would like to suggest crisis-based clinical supervision, a model that requires supervisors to lean more on the restorative domain of clinical supervision.

During the post-pandemic phase, while staff servicing clients and clients are still dealing with residues of the crisis, it is valuable to engage in crisis-based supervision. The crisis-based supervision model was developed to equip staff with the right tools to manage clients’ crises, a primary responsibility of behavioral health staff [19]. James and Gilliland[20] suggested that supervisors should focus on addressing burnout, vicarious trauma, and compassion fatigue that supervisees may experience due to their clinical work. The restorative domain of clinical supervision strongly encourages supervisors to minimize supervisees’ job-related stress and trauma [10, 11]. Supervisors should commit to learning more from supervisees about their perception of support to be emotionally equipped to engage in critical reflection about their work [21]. One model recommended to implement crisis supervision effectively is the CARE (context, action, response, and empathy) supervision model; it attempts to understand supervisees’ needs related to crisis-trauma and disaster-based counseling situations (Abassary & Goodrich, 2014) [22].

The context component in this model factors in the impact elements such as time, location, and logistics in a crisis. Context affords supervisees the opportunity to detect that everyone is part of systems that intersect and touch various people differently. Vicarious trauma experiences of supervisees significantly influence supervisees’ comprehension and assessment of their client’s context. Safety factors for both clients and supervisees should be reviewed within the context of applicable situations. The safety assessment must address all matters, including race, gender, ethnicity, religion, sexual orientation, socioeconomic class, etc. Supervisors need to be comfortable and equipped to manage these conversations that often are seen as challenging or uncomfortable.

“Action” which follows the first component, requires supervisors to tackle any arising needs and concerns of the supervisees and assist them with coming up with an intervention to take Care of the clients. The supervisor is expected to engage in check-ins to gauge the success of the selected interventions and avail themselves to offer immediate assistance. The response component tackles the post-crisis and follow-up; supervisors should review the crisis and interventions and determine gaps in Care if applicable. The last component is empathy, which requires the supervisor to respond with compassion and empathy to the supervisee’s concerns. Supervisors show empathic responses by cultivating a safe space for supervisees to engage in self-reflection around experiencing vicarious trauma; the supervisor will also underscore the critical value of self-care [22]. Empathy is presented as an element that enables emotional growth for supervisees working with clients in crisis and is considered the most vital aspect of the supervisor in engaging in the supervisory process [23].

Providing effective clinical supervision can be very challenging for supervisors without the right tools. Just Practice is a framework developed by Finn [24] to ensure that connection with others is done methodically to honor the full agency of the person with the least power in the relationship dynamic. The framework is comprised of five components: meaning, context, power, history, and possibilities. It aligns well with the CARE (context, action, response, and empathy) supervision model and the domains of clinical supervision. Table 1 illustrates tasks supervisors can engage in to provide supervision that helps supervisees feel seen, heard, supported, and psychologically safe.

Just practice [24]	Clinical supervision domains and sub-domain [12]	Supervisory tasks
Meaning: What assumptions are shaping one’s interpretation of the situation? How are those interpretations different from one another?; What is the significance of the encounter/relationship	Normative Importance/value of C.S.	Assess supervisee’s; Past experiences with supervision Current views on supervision Workload to help supervisees allocate time for supervisory sessions. Ability to be available for routine scheduled sessions
Context: How is this context shaping me as a supervisor/staff/co-worker? How are macro systems impacting my struggles? How do organizational and social contexts impact the workplace’s relation, trust, and psychological safety?	Restorative; Trust and rapport Formative; Finding time	Assess; How do interpersonal and social contexts shape the relation in the workplace? If context needs to be adjusted to facilitate the supervisory alliance If the context facilitates mutual learning
Power: How do we remain mindful of our own power and power imbalances? How do our histories shape our perspectives? How are power and inequality structured in our organizations and macro systems shaped?	Restorative; Supervisor advice/support	Assess; What forms of power need to be addressed in this process How can you use power to promote justice/belonging in the relationship? Practice Cultural humility (consider your bias, accountability, respect, and embrace difference).; Encourage the supervisee to develop the goal of C.S.; Promote self-care, self-compassion and
History: How does where we have been shaped where we are going? How do peoples’ past histories and experiences shape relationship-building?	Formative; Reflective practice	Create an opportunity for the supervisee to; Learn from and about their Practice with persons served Evaluate change over time in their practice Assess their critical consciousness about systemic challenges affecting the people served Reflect on conscious use of self Practice
Possibility: What can I learn from others? How can we learn from old decisions made?	Formative; Improve care/skills	Assess the supervisee’s skills, needs, and learning style Teach clinical skills Helps supervisee with managing persons served effectively

Table 1.

Application of the just practice framework to clinical supervision domains and sub-domain.

2.6 Clinical supervision in a hybrid world

During this workforce crisis, organizations need to be creative in creating flexible work environments that promote work-life balance and a supportive culture. Crisis clinical supervision can be facilitated virtually, providing the supervisor’s context and supervisee’s support it. Tele-supervision is the provision of clinical supervision via technology, and recently, there has been a notable increase in the use of such methods [25]. During the COVID-19 pandemic, telesupervision became many providers’ primary vehicle of clinical supervision. Telesupervision is a promising approach to attain results similar to in-person supervision in situations where face-to-face contact is impossible [26, 27, 28]. Martin et al. [29] outlined the following steps for the practitioner to be effective and efficient when engaging in clinical supervision: (a) clear expectations and goals for supervision must be established; (b) there is no size fit all medium and mode of telesupervision- adjustment must be made to address the need of the supervisee appropriately; (c) embed tele-supervision in a comprehensive framework rounded in educational principles; (d) focus on the supervisory relationship; (e) formulate a plan to manage technical problems; (f) pay attention to communication by not multitasking during the supervision session; (g) rethink continuity by the supervisor making themselves more available outside of scheduled supervision time; (h) protect online security, safety, and confidentiality; (i) build in additional time and; (j) review supervision arrangements frequently.

3. Conclusion

Despite high healthcare spending, people with chronic behavioral issues do not have great health outcomes. The triple aim of improving patients’ experience with healthcare systems, health outcomes, and reducing the cost per capita birthed the fourth aim, which focuses on the staff’s support and development. Supporting the workforce after the pandemic is necessary to attract and retain staff. Clinical supervision is one of the interventions often used to support clinicians in effectively managing job-related stress and competencies. Of the three domains of clinical supervision (normative, formative, and restorative), the restorative domain is the least discussed yet most important in addressing self-care-related matters. Considering that non-clinical staff like clinicians deal with the same trauma and stressors in their work, it is imperative to provide this group with clinical supervision using the crisis-based CARE (Context Action Response Empathy) supervision model through the just practice framework. This model leans toward restorative supervision, emphasizing self-care, empathy, and reflection. Knowing supervisors’ challenges with focusing on the restorative domain of clinical supervision, supervisors need the right tools to support their staff effectively. Supervisors can use The Just Practice framework to navigate through supervision models to include issues such as power, race, gender, religion, context, and history, which organically fall under the restorative domain of clinical supervision.