Consider the following scenarios:
A novice veterinarian asking for guidance in performing a technical procedure for the first time.
An experienced veterinarian calling a former classmate to discuss a challenging case that is not responding to treatment as expected.
A close veterinary colleague helping you navigate through a state board complaint against you.
A group of peer veterinarians meeting monthly to manage stresses associated with balancing family and career responsibilities.
The commonality in these examples is that they all provide opportunities for clinical supervision.
Clinical supervision is typically thought of as regular and frequent meetings between a supervisee and trained supervisor to engage in facilitated, reflective discussion regarding topics of professional relevance and importance.a Although clinical supervision is most commonly seen as helpful for inexperienced colleagues, the human health-care literature suggests that clinical supervision extends beyond helping new graduates and house officers to also supporting experienced peers.1,2 Importantly, clinical supervision is distinctly different from mentoring and teaching.3 Rather, clinical supervision offers a goal-directed, specific process and is recognized as a core competency in some professions.4,5
Defining Clinical Supervision
There is no single accepted definition of clinical supervision in the extant literature. Historical definitions emphasized an authoritative and hierarchical model of clinical supervision best illustrated by the use of terms such as “senior” and “junior.”1,6 More recently, however, this has been replaced by definitions emphasizing a collaborative and alliance-based connection between supervisors and supervisees.7–12 Although research specific to the hierarchical model needs further development, theoretical research in human medicine suggests that a strict hierarchical relationship yields less favorable results,11,12 and some fields of medicine, specifically psychology, have already adopted a collaboration-focused, rather than a hierarchy-focused, clinical supervisory relationship.4 This is worth considering in veterinary medicine, where hierarchical supervisory relationships are traditionally more common than collaborative supervisory relationships.
Other definitions of clinical supervision in the literature2,10,13,14 lack practicality or specific objectives, do not incorporate the most current research, or do not include definitions of component elements. Furthermore, some definitions imply that clinical supervision always exists separate from or in addition to the contemporaneous supervisory practices that exist in a clinical setting.2,10,13,14 Expanding an already large workload by incorporating additional tasks related to clinical supervision is likely to be impractical for most busy veterinary practitioners.
Milne8 has proposed that clinical supervision be defined as follows:
The formal provision by senior/qualified healthcare practitioners for an intensive, relationship-based education and training that is case-focused and which supports, directs, and guides the work of colleagues (supervisees) and has functions of (1) quality control (including “gatekeeping” and safe, ethical practice); (2) maintaining and facilitating the supervisees’ competence and capability; and (3) helping supervisees work effectively.
This definition incorporates the empirical evidence of collaborative supervision and uses language espousing a partnership between supervisor and supervisee. It has found some utility in the literature15–17 and was the basis for a systematic review16 of the impact of clinical supervision on effectiveness of care. An abridged definition has been used in several studies8,9,15,16,18 to provide some agreement on the functions and ideals of clinical supervision while the details continue to be debated. Further investigation is required to articulate specific aspects of the veterinary profession that should be encompassed in the supervisory relationship and to inform evidence-based practices to improve clinical supervision in the veterinary profession.
Because the clinical supervision literature is still in its relative infancy, a lack of clarity may exist regarding application of the “supervisee” term. Within the clinical supervision construct, supervisees are qualified practitioners, which means that students are generally excluded as supervisees.1,a Thus, when analyzing data on clinical supervision, we believe it is necessary to view clinical supervision as a distinct entity from clinical teaching, because the approach to teaching students would necessarily be different on the basis of their lower level of qualifications and experience. However, many of the learned skills that comprise the clinical supervision construct may also be applied to clinical teaching of students, and both have as their goals the improvement of patient care, development of clinical skills, and enhancement of clinical competence.4,9,15
The Need for Clinical Supervision in Veterinary Medicine
Empirical research supports the use of clinical supervision as a specific competency in several professions.15,16,19–22 Veterinary medicine has historically extrapolated information from human health care23,24 and will likely continue to benefit from this foundation. Clinical supervision in the human health-care professions has numerous positive effects: improved patient outcomes,16,25 promotion of professional development,25,26 reduced burnout,27 and enhanced job satisfaction.28 Additionally, there are indications of higher staff retention rates and increased practice profitability.26,29,30 Formal clinical supervision may offer veterinarians both a mechanism to more easily reach out for assistance and the infrastructure to do so.
Likewise, training clinical supervisors may allow them to provide more effective and more efficient collegial assistance and support. Correspondingly, some authors call for an increase in specific training for clinical supervision,31 citing literature that suggests improved efficacy of supervisors who undergo training.31,32 Although expectations for performance, knowledge, and skills of new veterinary graduates have been discussed,33,34 guidelines are lacking for how clinical supervision can be used to develop and support new graduates and experienced veterinarians in achieving these expectations. Simultaneously, the research necessary to support the development of these guidelines is missing.35
Many of the human health-care professions that have embraced clinical supervision have documented improvements in patient and physician outcomes as a result.4,15,16,19,36 A potential concern arises that patient care could suffer if supervisors spend more time on clinical supervision and allow care to be delivered by supervisees. However, this concern was shown to be unfounded in a systematic review by van der Leeuw et al.37 In addition, Snowdon et al16 determined that enhanced clinical supervision is associated with greater effectiveness of patient care in many different geographic locations and contexts, and Kilminster et al38 and Kilminster and Jolly6 concluded that clinical supervision has positive effects on patient outcomes. Cottrell et al39 suggested that lack of supervision can be harmful for patients in the fields of nursing, social work, and psychology, and Farnan et al25 found that enhanced clinical supervision of residents lowers patient complication and mortality rates in emergency departments, inpatient hospitals, and ambulatory surgery units.
The benefits of clinical supervision stretch beyond positive outcomes for patients to positive outcomes for supervisors, supervisees, and the organization.6 Benefits to clinical supervisors include fewer missed diagnoses, improved work satisfaction, and a feeling of value and usefulness.6,19,25,40,41 Being a more effective clinical supervisor was associated with a reduction in burnout in mental health nurses.3 This may have been due to improvements in the workplace culture, a contextual resource for resilience,42–46 among those who participated in clinical supervision training. The authors of 1 study3 suggested that viewing clinical supervision as an integral part of the duties of the supervisor, rather than an additional task, was important for effective clinical supervision. Furthermore, they revealed that the more time-poor staff became, the greater the need for effective clinical supervision. The same study3 also showed that supervisees enjoyed improvements to well-being and standards of practice after participating in a clinical supervision trial. Several studies26,30 have found that workplaces that support supervisory practices and train supervisors in how to conduct effective clinical supervision have improved staff retention. Another study25 showed improved resident learning outcomes, including enhanced performance on standardized testing, as a result of clinical supervision. As stated by Ducat and Kumar40 in their systematic review, “the consistency of positive findings in the supervision literature seems to support the fundamental value of this activity.”
A criticism of the current literature surrounding clinical supervision is the low number of studies included in each literature review and the limited number of subjects per study.16,21,25,37,47,48 Additionally, many of the studies are population specific (eg, rural health care or mental health nurses) and may lack generalizability to other health-care professions. This underscores the importance and necessity of continued work in evaluating, developing, and tracking outcomes for clinical supervision in veterinary medicine and the other health-care professions. Clinical supervision research in veterinary medicine may also be able to offer a perspective that is of value to other health-care professions.
Incorporating Clinical Supervision into Daily Practice
The model for clinical supervision proposed by Proctor11,12 has been widely used.48–50 This model describes 3 domains in which supervision may occur: the formative, normative, and restorative domains. These domains encompass a model of clinical supervision that a supervisor might use with a supervisee (the learner) or that might provide a framework for clinical supervision of peers in the workplace. Although each domain is crucial, any one individual might favor 1 or 2 domains more heavily than the others in practice.11,15
Veterinarians are likely to be most familiar with the formative domain in Proctor's model of clinical supervision. This domain focuses on building the knowledge and skills necessary for practice.11 Learning a new procedure and seeking advice on a patient that is not responding to treatment as expected are 2 of many examples for which the formative domain is used in clinical supervision. Veterinarians may not be aware that they are part of a process of clinical supervision when teaching a new skill or discussing a case. Recognizing these moments in the context of clinical supervision emphasizes how the Proctor model is functionally important for describing elements of clinical supervision that are already in place for both supervisors and learners.
Veterinarian supervisors may enter the normative domain when professional issues related to policies and procedures, boundaries, and ethics arise. The Association of American Veterinary Medical Colleges Competency-Based Veterinary Education framework recognizes ethical decision-making and compliance with legal and regulatory requirements as essential expectations of entry-level veterinarians.51,52 However, additional experience in practice and state-specific laws and regulations is often necessary to fully build these competencies in new graduate veterinarians or in remedial cases. A support structure or specific training in this subject is often implemented after a challenging event has occurred, rather than in a preventative capacity. Specific supervision and training would ideally be provided on a preventative basis. The example of a complaint to a state board is one that may require thoughtful processing on the part of the practitioner and may be complicated by issues regarding the case itself, returning to the formative domain, or that cause a decrease in well-being or job satisfaction for the veterinarian, providing an opportunity for exploration of the restorative domain of clinical supervision.
What veterinarians may be less aware of as a facet of clinical supervision is attention to the restorative domain. This domain focuses on enabling practitioners to better understand and manage personal wellness, burnout, and other issues surrounding the emotional burden of practice in the health-care professions.11 For example, the restorative domain of clinical supervision may help veterinarians develop coping strategies necessary to mitigate both typical (such as the stressors associated with day-to-day veterinary practice) and atypical (such as a complaint to the state board) job demands to avoid potential burnout.53–55 Practical ways to help supervisees build this domain may include modeling work-life balance, engaging in camaraderie, and providing feedback and empathy in situations that involve challenging clients or coworkers. Attention to the restorative domain might occur formally or informally in the clinical supervision process. Informal learning has been described by Swanwick56 as an important component to postgraduate learning. The social practice of informal learning among supervisees under the leadership of supervisors helps develop professional identity and shape workplace culture.56,57 Perhaps the restorative domain of the Proctor model for clinical supervision11 can offer some long-term solutions for the growing concerns about veterinarian mental health.
Examples of supervisory practices that have been generally agreed to be helpful include offering effective challenges, communicating support, and providing adequate instruction (Appendix).1–3,6,10,12–14,17,27,28,38,48,50,58–60,a Examples of clinical supervision practices that are considered unhelpful include a lack of awareness when a supervisee is in potential peril and an aversion to challenging of the supervisor's ideas. Whenever a veterinarian asks a supervisor or peer for help, recognition of the request as a clinical supervision opportunity, knowledge of the framework of clinical supervisory practices, and the ability to implement these would be helpful and be more likely to yield a positive outcome. Although it is unlikely that many practitioners have had specific education in clinical supervision,61 it is probable that practitioners have worked together to achieve the best possible outcomes for these types of situations. Imagine, however, the potential outcomes that may occur if specific support, education, and training in the 3 domains of clinical supervision were provided.
When thinking about how to incorporate support of and education and training in clinical supervision in the veterinary profession, it is may be helpful to examine what other professions have done. In 2015, the American Psychological Association developed guidelines to promote quality supervision through a competency framework that has been consensually agreed on and subsequently used on a practical basis.4 The assumption in these guidelines is that clinical supervision is a professional competency that requires formal educational training. Seven key domains for clinical supervision were included: supervisor competence; diversity; supervisory relationships; professionalism; assessment, evaluation, and feedback; problems of professional competence; and ethical, legal, and regulatory considerations. These guidelines offer a paradigm for best practices in clinical supervision for the psychology profession and have some basis in the Proctor model11: supervisor competence, professionalism, and assessment describe the formative domain, and problems of professional competence and ethical, legal, and regulatory considerations are part of the normative domain. However, they lack acknowledgment of the restorative domain, which is an important component of clinical supervision and one that we believe should be explicitly stated in best-practices guidelines on this topic. If similar guidelines are created in the veterinary profession, it should be with the intention of including all 3 domains from the Proctor model,11 including the restorative domain, to acknowledge and emphasize the importance of addressing the emotional challenges of practice. This would potentially position veterinary medicine as a leader among the health-care professions while addressing an ongoing concern in the profession.
Potential Mental Health Implications of Clinical Supervision
In a profession for which mental health and negative mental health outcomes are at the forefront of conversation,62–67 exploring possible protective mechanisms and enhancements to resilience, such as engaging in clinical supervision, is a logical next step. Studies66,68-70 have examined possible mental health trends early in the careers of veterinarians, particularly during the formative years in practice when clinical supervision may play a key role in career development. Emphasis on the restorative domain of clinical supervision would help to address the growing concern surrounding mental health in the veterinary profession by potentially offering support for both seasoned practitioners and new graduates, with both supervisors and supervisees expected to benefit from clinical supervision.
In response to the problems of mental ill-health, burnout, and suicide in veterinary medicine, there has been a call to focus on solutions-based approaches to these problems.46,71,72 One such approach is developing resilience in veterinary practitioners and students.45,73,74 Resilience in the veterinary profession was defined by McArthur et al75 as a “dynamic and multifaceted process in which individuals draw on personal and contextual resources, and use specific strategies to navigate challenges and to work toward adaptive outcomes.” Clinical supervision is a potential target for improvement of contextual, or workplace, resources that would yield improved resilience. Because resilience is a learned process rather than an innate attribute,42,54 the effectiveness of training in clinical supervision to improve contextual resources for resilience becomes a logical focus for future research.
Specifically, exploration and incorporation of the restorative domain in clinical supervision may help improve resilience and mental health in the veterinary profession. Veterinarians in the United Kingdom reported professional relationships with colleagues as being an important resource for job satisfaction,74 and Bartram et al76 theorized that “the development of a workplace culture in which there is regular constructive feedback and problems are addressed sensitively could generate a more supportive work environment. Opportunities for clinical supervision, mentorship and review could be expanded and collaborative team-working encouraged.” In a 2014 survey-based study of 274 veterinarians, Moore et al77 showed that team effectiveness, an example of workplace culture, can influence job satisfaction of individual workers. Supervisor support has been shown to be a beneficial job resource for veterinarians and is negatively related to exhaustion.78 Effective clinical supervision that would be helpful for mental health may thus include a focus on mentoring, providing support in challenging situations, and implementing practices and processes that would encourage a positive workplace culture and facilitate restorative practices. These practices should include clinical supervision to help support clinical supervisors as well as supervisees and should be structured to include education on clinical supervisory practices and recognition of clinical supervision as a core competency.
Recommendations
We recognize that some veterinary organizations have guidelines delineating the requirements of residency training programs and internships and approaches to new graduate training or continuing education. Although useful for standardizing program requirements, these are distinctly different from guidelines on best practices for clinical supervision. We believe that guidelines on clinical supervision in veterinary medicine should be developed to train, educate, and support clinical supervisors, describe essential practices for clinical supervision, and establish a competency framework for delivery of quality supervision in veterinary medicine. Ideally, these guidelines should be based on evidence originating in the veterinary profession. Such a proposition is predicated on additional research on this topic in veterinary medicine, which requires a working definition to align these efforts.
Currently, a definition of clinical supervision specific to veterinary medicine remains absent from the literature, and those that exist in other professions fail to adequately address well-being. Given the potential importance of clinical supervision to veterinarian mental health, we propose a provisional definition of veterinary medical clinical supervision that is adapted from the one offered by Milne,8 follows the Proctor model11 in its emphasis on the 3 domains of clinical supervision, and explicitly includes the restorative domain through an emphasis on fostering collaborative relationships and enhancing mental health among practitioners.
We propose, therefore, that clinical supervision in veterinary medicine be defined as follows:
Clinical supervision represents the formal and informal provision by qualified veterinarians of professional, relationship-based, collaborative supervisee training that supports, directs, and guides the work of colleagues (supervisees) to enhance knowledge and skills, ensure quality control and ethical practice, and maintain well-being and resilience. The overall goal of this process is to enhance professional capabilities, ensure the best possible patient outcomes given available resources, and foster well-being, competence, and effectiveness for supervisors and supervisees.
Conclusions
Human medicine has issued a call for additional research in clinical supervision,6,21,48 but the veterinary profession has yet to hear a similar call to action. Currently, there are no established guidelines or training practices for clinical supervision in the veterinary profession, and research on clinical supervision in veterinary medicine to support such guidelines is virtually nonexistent. Given the literature in human health care, veterinary medicine would be well placed to benefit from wider practice of clinical supervision. The need for empirical evidence to support adequate supervisory practices is apparent. A theoretical approach to modeling clinical supervision, such as that proposed by Proctor11 with formative, normative, and restorative domains, may be used to address the urgent need for research in the absence of robust, controlled trials on best practices for clinical supervision.
As future research is developed, we encourage researchers to keep in mind the shared goals for clinical supervision, which include better patient and client outcomes, improvement of practitioner skills, higher staff retention, lower burnout rates, and an overall improvement in well-being. This foundation will provide a basis upon which to develop the evidence-based, practical, and readily usable guidelines for clinical supervision and training that are currently conspicuously absent from this conversation in veterinary medicine. Developing these guidelines may be a potential focus for professional associations in veterinary medicine to articulate best practices and assist clinicians in their crucial role of clinical supervision in the workplace.
Acknowledgments
No third-party funding or support was received in connection with the writing or publication of this manuscript. The authors declare that there were no conflicts of interest.
Footnotes
White E. Clinical supervision: predicting best outcomes (abstr). 43rd Biennial Conv Sigma Theta Tau Int, Honor Soc Nurs 2015.
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Appendix
Helpful and unhelpful practices for clinical supervision.1–3,6,10,12–14,17,27,28,38,48,50,58–60,a
Helpful practices
Offering effective challenges.
Maintaining respectful engagement between supervisor and supervisee.
Forming a positive supervisory relationship and alliance.
Collaboratively assessing supervisee competence.
Incorporating opportunities for supervisee self-assessment and goal setting.
Identifying challenges in the supervisory relationship and openly discussing them.
Clarifying the roles of the supervisor and supervisee.
Reflecting on worldviews, attitudes, and biases and considering these in the process of clinical supervision.
Demonstrating an ability to share ideas and experiences in a way that is helpful to the supervisee.
Communicating support.
Monitoring and protecting patients and clients and displaying transparency in your gatekeeping role.
Offering opportunities for stress management, such as counseling and personal days.
Providing adequate instruction and protection for supervisees performing procedures that involve risk (eg, animal handling and exposure to infectious diseases).
Unhelpful practices
Establishing a predominantly hierarchical rather than collegial relationship.
Failing to help the supervisee explore beyond what they already know.
Avoiding contention or challenging of ideas.
Lacking awareness, empathy, or understanding of the supervisee's learning process.
Being inconsistent and overly demanding.
Being competitive with the supervisee.
Allowing the supervisee to dictate the terms of the supervisory relationship in ways that inhibit learning (eg, using supervision as therapy or disregarding instruction and advice).