Could clinical supervision help us to support increasingly complex needs in the community?

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  • 1 Independent researcher, , UK
  • | 2 Fulfilling Lives South East, , UK
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This paper presents qualitative research exploring the benefits of clinical supervision for workers supporting people experiencing multiple disadvantages. The clinical supervision supported worker wellbeing, lessened compassion fatigue and created space for workers to think creatively, manage risk and develop trauma-informed and reflective practice. Clinical supervision may be one solution to the growing demand, more complex needs and higher stress, burnout and fatigue among workers faced by the voluntary sector following the COVID-19 pandemic.

Abstract

This paper presents qualitative research exploring the benefits of clinical supervision for workers supporting people experiencing multiple disadvantages. The clinical supervision supported worker wellbeing, lessened compassion fatigue and created space for workers to think creatively, manage risk and develop trauma-informed and reflective practice. Clinical supervision may be one solution to the growing demand, more complex needs and higher stress, burnout and fatigue among workers faced by the voluntary sector following the COVID-19 pandemic.

Introduction

Since the start of the COVID-19 pandemic, needs in the community have changed – and the voluntary sector must look for ways to adapt to its new environment. Organisations are now supporting a greater number of individuals than ever before (Lloyds Bank Foundation, 2020; The National Lottery Community Fund, 2020). Additionally, those individuals are presenting with more complex needs, particularly in fields such as housing and mental health (NCVO, 2020; Sheehan et al, 2020; Pixley et al, 2021; Thiery et al, 2021). These changes come against a backdrop of reduced support worker capacity and persistent underfunding during the pandemic (Grønbjerg et al, 2021). As the impacts of COVID-19 continue to be felt, it is predicted that these changes in the level of need and complexity are unlikely to return to pre-pandemic levels in the near future (Chan et al, 2021).

This changing environment increases pressure across the entire sector (IVAR, 2020), but may particularly impact support workers, who provide the direct, person-facing response. An emerging body of evidence is highlighting stress, burnout and fatigue as a serious concern in support staff and volunteers since the start of the pandemic (Chirico et al, 2021; Pixley et al, 2021; Thiery et al, 2021). Those supporting people experiencing complex trauma may also experience vicarious traumatisation, as well as the impacts of ‘direct threats to physical and emotional safety’ that may occur in the course of their work (Fallot and Harris, 2001).

It is clear that organisations have a duty of care to create a supportive environment for support workers who are helping others during an extremely challenging time. They also need to help workers develop the skills to address the increased complexity of need (Chirico et al, 2021; Pixley et al, 2021; Thiery et al, 2021). In addition, burnt-out staff are likely to provide poorer support due to fatigue and to take sick leave or leave their roles to try to recover (Briner et al, 2008). These issues could exacerbate existing staffing challenges and create additional recruitment costs.

This paper explores the use of clinical supervision as a way to help support workers to address their changing working environment. It defines clinical supervision and its current usage, and describes new qualitative research that demonstrates the impacts of clinical supervision for workers within a small project supporting people experiencing multiple disadvantages. Finally, the paper discusses how this new research might contribute to our understanding of how clinical supervision could be applied within the voluntary sector.

The paper aims to advance the literature relating to COVID-19 by assessing a practical solution to the documented issues faced by support workers since the start of the pandemic. It is hoped that the paper will inform service design by voluntary sector providers, and inform the thinking of grant funders and statutory sector commissioners.

What is clinical supervision and where is it currently used?

Defining clinical supervision

Clinical supervision is a form of supervision that supports workers in roles that provide direct support to people. It has been defined as: ‘The formal provision, by approved supervisors, of a relationship-based education and training that is work-focused, and which manages, supports, develops and evaluates’ (Milne, 2007: 437). Unlike more commonly used managerial supervision, the clinical supervisor does not seek to gain oversight of project activities, and is not primarily concerned with ensuring that the worker’s behaviour meets organisational expectations. Instead, the clinical supervisor is a resource for individuals to work through situations they have found challenging, and to receive theory and new approaches that could support them in their work. The clinical supervisor is typically external to the service, and has experience in the area their supervisee is practising in. Supervision can happen one to one or in a group, and takes place at regular intervals.

The British Association for Counselling and Psychotherapy (BACP) describes three key functions of clinical supervision (Corrie and Birch, 2014). The first is the ‘normative’ function, which supports the development of knowledge, skills and abilities, by bringing in relevant research or theory. The second function is ‘formative’, which supports ethical practices and safeguarding decisions and provides quality assurance. The third function is ‘restorative’, which supports workers to reflect on the emotional impact of their work, and the contextual factors that may enable or constrain learning and development.

Current usage

Clinical supervision (alongside associated terms such as ‘external supervision’ or ‘clinical social work practice’) is traditionally discussed in social work literature (Corcoran and Walsh, 2010; Kadushin and Harkness, 2014). Statutory sector mental health and nursing have also generated a moderate amount of research evidence supporting the benefits of the practice (Wheeler and Richards, 2007; Brunero and Stein-Parbury, 2008; Gonge and Buus, 2011).

Within the voluntary sector, clinical supervision is much less used and evaluated, despite calls to integrate its use (Clarke, 1997; Jenkinson, 2011). However, small-scale research indicates that positive impacts have been observed where it has been implemented. Housing support workers in the United Kingdom indicated that regular clinical supervision increased professional confidence and significantly reduced burnout (Maguire et al, 2017). A health and care service recorded increased worker wellbeing, engagement and motivation, and decreased absence and retention issues, following the introduction of clinical supervision (Harrison, 2019). Finally, staff at a youth support service unanimously felt that clinical supervision improved their practice, and an increase in positive move-on from the service was recorded (Homeless Link, 2017).

Our research

The research on which this paper is based focused on a small project that works with people who are experiencing multiple disadvantages (also known as multiple and complex needs) in the south-east of England. ‘Multiple disadvantages’ was defined as recent experience of three or more of the following issues: mental health issues, homelessness, drug or alcohol issues and offending.

The project employed six support workers, led by three local managers. They each provided intensive, flexible support for small caseloads of approximately six to ten people. They often lone-worked to provide assertive outreach interventions, supporting people to access statutory health services, address substance misuse issues and sustain accommodation. Because of the intensity of the work, external one-to-one clinical supervision for workers had been provided by the project since January 2016.

Workers received clinical supervision sessions every six weeks with a supervisor who had relevant work experience. Sessions lasted approximately one hour and 15 minutes. They took place in person until March 2020, when they moved online due to COVID-19 restrictions.

Eight semi-structured interviews were conducted, with support workers (n = 5), managers (n = 2) and the clinical supervisor (n = 1). The support workers had been in post for between 18 months and four years. They included two women who were women’s specialist workers, and three men who supported people affected by co-occurring substance misuse and mental ill-health. All five engaged fully with the clinical supervision.

The research sought to answer the question: ‘What has been the impact of clinical supervision on support workers, working practices and the people being supported?’ This paper focuses primarily on describing these impacts and learning for future practice.

The perceived impacts of clinical supervision

Formative impacts

The support workers interviewed described the value of bringing challenging situations to clinical supervision sessions in order to unpick and advance them with the supervisor’s input. Clinical supervision was thought to enable supervisees to better understand the behaviours of the people they were supporting, and gain insight into processes within the worker–client relationship. The clinical supervisor emphasised the importance of this process and providing “the opportunity of trying something different” for workers who felt stuck. This resulted in new enthusiasm for the work and keeping cases open in creative, trauma-informed ways, where previously case closure would have been considered.

A key part of this process was grounding supervisees’ experiences in relevant theory, and challenging perceptions with alternative narratives. This input of trauma-informed theory was felt to have a positive effect on workers’ empathy and compassion in complex situations. One worker explained: “Once you understand the behaviour it makes a lot of sense; they’re not just shouting everywhere they go, they’re shouting when they don’t feel safe, so let’s understand that.”

Clinical supervision also allowed space for workers to reflect on why some people’s behaviour elicited particular responses in them, and how to break relationship-based cycles in order to model healthy relationships. One interviewee explained that “[the clinical supervisor] is aware of key things that have happened in my life, which then kind of make sense as to why a certain element of a client’s behaviour is triggering something in me”.

Workers believed that as a result of supervision enhancing their practice in these ways, the people they were supporting generally felt better understood, were better advocated for and felt increased trust in the worker–client relationship. These impacts were particularly pertinent to the individuals supported by the project, who may not have had the opportunity to build trusting relationships in the past, and where services understanding their behaviours could mean the difference between maintaining housing and being evicted. One interviewee explained:

‘I was working with a client in a hostel. She was being threatened with eviction. I couldn’t get them to understand where she was coming from. I spoke to [the clinical supervisor] and she helped me advocate for her. The eviction got revoked because they could understand that behaviour instead of seeing it in a different way. At first they saw it as a negative behaviour against the hostel and actually it wasn’t, it was a trauma behaviour … That’s kept someone a home.’

Normative impacts

Those interviewed felt that clinical supervision provided a focused space to work through complex safeguarding and ethical issues in a way that complemented managerial supervision. While a line manager would focus on adhering to procedures and ensuring safety (including closing cases if needed), a clinical supervisor would provide a theory-led space for the worker to explore different ways to continue to safely work with a person. The in-depth discussions that were possible in clinical supervision meant the clinical supervisor was sometimes in a better position than a manager to observe when workers were unwell or unable to practise safely. These functions were valued by both support workers and managers. The confidential nature of clinical supervision was valued by support workers because they felt comfortable to be honest about their feelings. This was respected by managers, who did not report tensions between this confidentiality and their aims.

Workers were supported to manage high levels of risk, and to consider their own wellbeing and boundaries during complex safeguarding situations. One interviewee reflected: “It was always useful talking to [the clinical supervisor] because it was like actually I should be a bit worried about this, rather than being quite blasé about things.” Clinical supervision provided a continuous outside perspective on how risks might be managed by the project, allowing for high standards of safety.

Restorative impacts

The clinical supervisor was seen as someone who reignited compassion for people experiencing complex disadvantages, at times when workers were struggling with motivation and empathy: “It has eliminated compassion fatigue for me; I haven’t felt that with any clients. The ones I get close to feeling like that, [the clinical supervisor] has been able to renew some enthusiasm for me.”

Several interviewees described the importance of being supported through stressful periods when they believed they had been at significant risk of burning out. Having a dedicated space to talk through the impact of the major crises or deaths of those being supported were highlighted as particularly protective practices. Interviewees felt that clinical supervision also improved worker resilience:

‘Recently, I’ve been working with this case and I’ve tried so many things that haven’t worked out. One of my colleagues was saying to me: “You’re so calm about it! You’ve put all that time into this and then it didn’t work out.” And I was like: “Oh yeah, that’s alright, we’ve just eliminated that as a possibility, let’s move on to the next thing we can try.”’

The specialist women’s workers in particular reported a much higher emotional toll from the work than those who worked primarily with men, and highly valued the restorative impacts of clinical supervision. This was because women receiving support were reported as being more likely than men to experience traumatic experiences such as sexual abuse, abusive relationships and experiences around pregnancy and the loss of children into care.

Having workers who were able to be present as a stable supporter in times of chaos was considered particularly beneficial to the people receiving support. On the other hand, it was seen as potentially destabilising when workers required time off for sickness or left their roles, leaving people with new workers and without the trusting relationships that had been built up over time.

How clinical supervision could be applied in the non-profit sector

In a project that focuses on supporting people experiencing multiple disadvantages, clinical supervision provided wide-ranging benefits to workers, managers and the people receiving support. But what are the conditions that allow this practice to have maximum impact in an organisation, and how viable is it for smaller voluntary sector organisations to implement it?

When clinical supervision is particularly valuable

Clinical supervision was considered to be particularly valuable to workers in three circumstances:

  • when workers were working intensively with a small number of people who were experiencing complex health and social care needs – this was because of the intensity of worker–client relationships and the degree of creativity required to maintain positive momentum with a small group of individuals;

  • when workers were likely to conduct lone-working or had minimal opportunities to receive peer support;

  • when workers had lived experience of the issues they were supporting people with, because of the additional complexities of managing their prior experiences within the role.

Ensuring maximum impact of clinical supervision sessions

Clinical supervision can be approached in many ways, depending on the practitioner’s skills, the organisation’s needs and the wider context of the work. In the project the research was conducted within, the following elements were recognised as important to maximise the impact of the intervention:

  • a clear structure to sessions and the scope of the role;

  • supervisee-led sessions that were responsive to different needs;

  • supervisor awareness of trauma and experience of the group being supported;

  • flexibility of location and scheduling (so workers could stay responsive to people’s needs);

  • additional telephone support between sessions for exceptional impactful events.

Support workers maximised the value of the sessions by blocking out time before and after supervision sessions for preparation and reflection. Raising alternative narratives of client behaviours in wider project meetings was also important in maximising the impact of the intervention beyond direct support staff.

Many support workers felt that the one-to-one support format was valuable, as it allowed them to explore personal issues, set the agenda and receive in-depth support. This was particularly important given the complexity and trauma experiences of the people being supported. A small number of group supervision sessions had also been arranged, which provided an opportunity for peer support and peer-generated solutions.

Financial viability

While there is a clear ethical responsibility to properly support staff in the voluntary sector, it is pragmatic to consider the cost of delivering any additional support practices. Although the current research did not explicitly seek to conduct a costing exercise, findings relating to potential reductions in worker sickness and staff turnover provide an interesting insight into potential affordability.

Support workers indicated that they took less leave as a direct result of receiving clinical supervision. One interviewee shared that: “I thought I was going to fall apart. I spoke with [the clinical supervisor] … That helped me through and meant I didn’t have to take any time off work.” Table 1 suggests that if clinical supervision did indeed support a worker to stay in post, the costs of the intervention would be partly offset by the associated recruitment saving and reduced sickness absence, in this particular project. These costings do not account for softer impacts such as reductions in support time from line managers, worker time spent covering other roles and better-quality outcomes for people receiving support (for example, remaining in accommodation, better health or reduced substance use), which may result in less intensive support being needed.

Table 1:

Average costings of sickness absence, recruitment and selection compared with clinical supervision

Annual cost of providing clinical supervision for one worker in the case study project (based on £65 per session per worker, once every six weeks)£563
Average cost, per recruit, of recruitment and selection in the third sector (Agenda Consulting, 2019)£1,612
Average annual cost of sickness absence per full-time employee in the third sector (Agenda Consulting, 2017)£843

Discussion

This paper describes a small-scale research project focusing on a programme aimed at supporting people experiencing complex disadvantages. It provides a promising indication that clinical supervision may be beneficial when supporting ever-more complex needs in the community. However, the research outlines one approach to supervision in one type of organisation, and different fields may have different needs. As such, there are limitations to the generalisability of its findings, and further research to test the findings in different contexts would be beneficial.

As funding levels reduce, volunteers may be increasingly utilised to conduct direct support work in the voluntary sector. The evidence presented in this paper about emotional impact and the level of skill that support work requires raises important questions about the appropriateness and risks of volunteers taking on increasingly complex roles. Where volunteers are working in this way, it is likely that they would benefit from the formative, normative and restorative elements of clinical supervision. The implementation of this type of support with volunteers – and its uptake – could usefully be explored further.

Finally, as the voluntary sector begins to reflect more on issues relating to race, gender, gender identity, sexuality and class and the intersections between these, clinical supervision may provide a valuable space for reflection and support for workers. It might also help organisations to respond better to the range of needs of the people they support. Recruiting a clinical supervisor with awareness and skills around these issues would be important.

Conclusion

This research adds to the growing evidence base indicating the benefits of clinical supervision as one option for supporting workers in the voluntary sector, at a time when the needs of the community are changing. In the context of a small project supporting people experiencing multiple disadvantages, the practice created space for support workers to think creatively, manage risk and lessen compassion fatigue. However, clinical supervision is one of many potential options, and should be provided on a foundation of appropriately funded posts, training opportunities and a positive working culture in order to be as impactful as possible.

Perhaps, with the withdrawal of statutory support in a number of areas (Lloyds Bank Foundation, 2020), it is unsurprising that the typically statutory practice of clinical supervision is of increasing relevance in other sectors. In a climate where funding limitations continue to reduce services, it is reassuring that clinical supervision may not be as financially prohibitive as previous voluntary sector literature believed (Jenkinson, 2011). There is cause for optimism too in that trauma-informed practices such as clinical supervision appear to be increasingly valued and discussed by those commissioning services.

The configuration, scale and nature of support vary enormously across the voluntary sector. The way clinical supervision is implemented should be sensitive to and embrace these differences. Finding a supervisor and implementation method that suits a particular organisation also appears to be important in terms of getting the best out of the intervention.

Recent literature is clear that voluntary sector staff are being negatively impacted by the demands placed on them during the pandemic. It now feels important to advance the conversation by trying and evaluating pragmatic solutions to better support them.

Funding

This work was supported by The National Lottery Community Fund under grant 10077955.

Conflict of interest

The authors declare that there is no conflict of interest.

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    • Export Citation
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    • Export Citation
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    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
  • Agenda Consulting (2017) People Count third sector 2017: HR and workforce benchmarks for the third sector, Absence Management, 2(4): 142.

    • Search Google Scholar
    • Export Citation
  • Agenda Consulting (2019) Charities in the UK: findings from People Count 2019 study, https://www.agendaconsulting.co.uk/2019/10/15/charities-in-the-uk-findings-from-the-people-count-2019-study/.

    • Search Google Scholar
    • Export Citation
  • Briner, R.B., Poppleton, S., Owens, S. and Kiefer, T. (2008) The Nature, Causes and Consequences of Harm in Emotionally-demanding Occupations, London: Birkbeck College, University of London for the Health and Safety Executive.

    • Search Google Scholar
    • Export Citation
  • Brunero, S. and Stein-Parbury, J. (2008) The effectiveness of clinical supervision in nursing: an evidenced based literature review, Australian Journal of Advanced Nursing, 25(3): 8694.

    • Search Google Scholar
    • Export Citation
  • Chan, O., Fern, J., Goodall, C., Jochum, V., Vibert, S., Walker, C., Winyard, P. and Young, R. (2021) The road ahead 2021: a review of the sector’s operating environment. London: NCVO.

    • Search Google Scholar
    • Export Citation
  • Chirico, F., Crescenzo, P., Sacco, A., Riccò, M., Ripa, S., Nucera, G. and Magnavita, N. (2021) Prevalence of burnout syndrome among Italian volunteers of the Red Cross: a cross-sectional study, Industrial Health, 59(2): 11727. doi: 10.2486/indhealth.2020-0246

    • Search Google Scholar
    • Export Citation
  • Clarke, J. (1997) Managing Better: A Series on Organisational and Management Issues for the Community and Voluntary Sector: Staff Support and Supervision, Dublin: Combat Poverty Agency.

    • Search Google Scholar
    • Export Citation
  • Corcoran, J. and Walsh, J. (2010) Clinical Assessment and Diagnosis in Social Work Practice, Oxford: Oxford University Press.

  • Corrie, S., Birch, J. (2014) Fit for purpose: getting the best supervision for your practice. Coaching Today, 12: 2630.

  • Fallot, R. and Harris, M. (2001) Creating cultures of trauma-informed care (CCTIC): a self-assessment and planning protocol, https://www.theannainstitute.org/CCTICSELFASSPP.pdf.

    • Search Google Scholar
    • Export Citation
  • Gonge, H. and Buus, N. (2011) Model for investigating the benefits of clinical supervision in psychiatric nursing: a survey study, International Journal of Mental Health Nursing, 20(2): 10211. doi: 10.1111/j.1447-0349.2010.00717.x

    • Search Google Scholar
    • Export Citation
  • Grønbjerg, K.A., McAvoy, E. and Habecker, K. (2021) Indiana mon-profit organisations and COVID-19: impact on services, finances and staffing, Voluntary Sector Review, 12(1): 1237.

    • Search Google Scholar
    • Export Citation
  • Harrison, J. (2019) An Evaluation of the Clinical Supervision Pilots, Liverpool: Riverside Care and Support.

  • Homeless Link (2017) Reflective Practice in Homelessness Services: An Introduction, London: Homeless Link.

  • IVAR (2020) A Funding Cliff Edge? Briefing 4 on the Challenges Faced by VCSE Leaders during the COVID-19 Crisis, London: IVAR.

  • Jenkinson, H. (2011) An exploration of the importance of supervision practice in the voluntary sector, Voluntary Sector Review, 2(2): 23946. doi: 10.1332/204080511X583887

    • Search Google Scholar
    • Export Citation
  • Kadushin, A. and Harkness, D. (2014) Supervision in Social Work, New York, NY: Columbia University Press.

  • Lloyds Bank Foundation (2020) Small Charities Responding to COVID, London: Lloyds Bank Foundation.

  • Maguire, N., Grellier, B. and Clayton, K. (2017) The Impact of CBT Training and Supervision on Burnout, Confidence and Negative Beliefs in a Staff Group Working with Homeless People, Unpublished Typescript, School of Psychology, Southampton: University of Southampton.

    • Search Google Scholar
    • Export Citation
  • Milne, D. (2007) An empirical definition of supervision, The British Journal of Clinical Psychology/The British Psychological Society, 46: 43747. doi: 10.1348/014466507X197415

    • Search Google Scholar
    • Export Citation
  • NCVO (National Council for Voluntary Organisations) (2020) The Impact of COVID-19 on the Voluntary Sector, London: NCVO.

  • Pixley, C.L., Henry, F.A., DeYoung, S.E. and Settembrino, M.R. (2021) The role of homelessness community based organizations during COVID‐19, Journal of Community Psychology, doi: 10.1002/jcop.22609[Epub ahead of print]

    • Search Google Scholar
    • Export Citation
  • Sheehan, R., Dalton-Locke, C., Ali, A., Totsika, V., San Juan, N.V. and Hassiotis, A. (2020) Mental healthcare and service user impact of the COVID-19 pandemic: results of a UK survey of staff working with people with intellectual disability and developmental disorders, medRxiv, https://www.medrxiv.org/content/10.1101/2020.09.01.20178848v1.

    • Search Google Scholar
    • Export Citation
  • The National Lottery Community Fund (2020) Voices from the frontline, https://www.tnlcommunityfund.org.uk/insights/covid-19-resources/responding-to-covid-19/voices-from-the-pandemic-interviews-from-the-frontline.

    • Search Google Scholar
    • Export Citation
  • Thiery, H., Cook, J., Burchell, J., Ballantyne, E., Walkley, F. and McNeill, J. (2021) ‘Never more needed’ yet never more stretched: reflections on the role of the voluntary sector during the COVID-19 pandemic, Voluntary Sector Review, 12(3): 45965. doi: 10.1332/204080521X16131303365691

    • Search Google Scholar
    • Export Citation
  • Wheeler, S. and Richards, K, (2007) The impact of clinical supervision on counsellors and therapists, their practice and their clients: a systematic review of the literature, Counselling and Psychotherapy Research, 7(1): 5465. doi: 10.1080/14733140601185274

    • Search Google Scholar
    • Export Citation
  • 1 Independent researcher, , UK
  • | 2 Fulfilling Lives South East, , UK

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