This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information
Section two: Theoretical models of supervision
The theoretical models of supervision (for example, those reviewed by Bernard and Goodyear [1992]) provide a broad supervisory framework. Supervision methods and techniques, such as giving feedback, challenging beliefs and shaping behaviour, tend to be relevant to specific situations. When supervisees find themselves sitting opposite a supervisor and wondering how to proceed, they often find that their needs fall somewhere between a broad framework and specific interventions. Their common question is "What should I actually do in supervision?" The purpose here is to present two important methods or approaches to clinical supervision; firstly, a Supervision Triangle which provides a template for the important areas to be addressed in supervision, and their application in practice, and secondly, The Integrative Development Model which provides an insight into the process of clinical supervision.
The Supervision Triangle
The Supervision Triangle was developed from an adaptation of Wagner's (1957) concept that different supervisors tend to focus predominantly on one of three parameters. Supervision can be patient-centred (focusing on technical issues of case management), practitioner-centred (focusing on the practitioner's reactions and problems) or process-centred (focusing on the interaction between patient, practitioner and supervisor). The first form of the Supervision Triangle was simply a diagrammatic representation of Wagner's three supervision foci, with one focal point in each of three cells within the triangle and with a more generic terminology ("patient/client" and "practitioner"). The three-celled triangle assumes that supervision should not always focus on only one cell. Rather, a particular supervisory relationship should sometimes be client-focused sometimes practitioner-focused and sometimes process-focussed. Use of that simple triangle led to modifications and expansion, resulting in the diagram below.
Figure 2A: Diagram of the supervision triangle
Use of the supervision triangle
The issues likely to be addressed within each cell can vary in different supervisory relationships, depending upon the orientation being applied and the context of the supervision. Examples of the relevant questions to be addressed in each of the different cells are provided in Appendix 1.
There are two specific ways in which the supervision triangle can be applied; the first approach involves the use of guided reflection (partially objective), and the second approach relies upon self-reflection (subjective). The diagram below presents an overview of the two approaches:
Figure 2B: The use of the supervision triangle
The four key areas within the outer circle, in themselves, represent a process of application for clinical supervision. Supervision goals are set, cases are reviewed and discussed, supervision is then evaluated within all the triangle cells, and then the whole clinical supervision process is reviewed and new contractual agreements made. Of course there is flexibility in how you decide to implement this model; the process outlined does not have to be adhered to, although the initial 'goal setting' phase is an important starting point. In each instance, the relevant cells of the supervision triangle are selected and the significance and impact of ethnic and cultural diversity is explored.
1. Guided reflection
(a) Goal setting
When the goals and methods of supervision are being negotiated, the triangle provides a template for the areas that might be included. Reviewing the practitioner's current functioning within each cell allows an identification of their needs (including cultural needs) and provides a common language for later supervision sessions. The goal-setting phase is also an appropriate time for modifying the triangle to meet individual needs by replacing irrelevant cells and revising the list of issues to be addressed within each cell. For example, the health visitor or nurse practitioner may wish to rename cells in line with the nursing process; assessment, planning, implementation and evaluation. Alternatively, the community health care practitioner may wish to replace 'parallel patterns' with multi-agency partnerships.
Three cells, which have particular relevance during the 'goal setting' phase, are those of
- Skills/Knowledge
- Professional Identity, and
- Self.
If it is recognised during this phase that the practitioner does not have the appropriate skills or knowledge to work with the intended client population, or within the required clinical area of practice, then either co-working partnerships could be identified or necessary training established. Special attention to the 'Professional Identity' cell allows the identification of supervision methods (for example, the degree of structure or the degree of interaction) that are congruent with the practitioner's stage of professional development. Discussion of the 'Self' cell allows the supervisor to gain informed consent for any "self" work that is relevant to the caring work being supervised and to create openings for the discussion of issues within this cell at a later time.
The negotiation of the clinical supervision methods to be used also raises the opportunity for the supervisor and supervisee to explore their cultural differences, and to learn more about their own, and other values and belief systems.
(b) Case discussions
The triangle provides a useful template for case discussions, both by triggering areas for discussion and allowing a prioritising of areas to be addressed within the time constraints of each session. A three-step procedure has been found to be effective.
I. Firstly, the practitioner provides a brief description of the case they wish to discuss.
II. The practitioner and supervisor then review the issues that might be relevant to the case within each cell.
III. Finally, the practitioner is given the responsibility for selecting which cells will be addressed during the session and which one will be used as a starting point.
Unless there are ethical or theoretical reasons for the supervisor to override these choices, the case discussion could then proceed with a focus on the chosen cells and issues. This procedure both contributes to the practitioner's self-direction and training in conceptualising supervision issues, and also capitalises on their readiness to deal with particular issues, thus reducing anxiety or possible "resistance".
The health care practitioner may find it useful to draw upon other health care models of practice during this approach; for example, if the supervisee wishes to reflect upon their caring relationship with the client it may be suitably appropriate to draw upon transcultural models in health care practice, such as Giger and Davidhizar (1999) or Purnell and Paulanka (1998). The use of transcultural models will facilitate the reflection process, allowing for greater insight.
(c) Evaluation
If a formal contract of evaluation has been commissioned or agreed with the practitioner, or other relevant participants or agencies, then a safe and known structure is provided for the practitioner to use, with an opportunity for them to self-monitor their progress. Evaluations will be conducted within each of the 12 cells.
(d) Review and re-contracting
One of the interesting uses of the triangle is for the supervisor and practitioner to review their supervision work together by discussing the extent to which they have been addressing each cell in recent supervision sessions. Do some cells get much more attention than others? Is this appropriate? Or is it related to restraints on the part of the supervisor or the practitioner about addressing certain cells? What might be different if infrequently used cells were given more priority in supervision?
Regular re-contracting, regarding which cells require priority and which issues need to be addressed within each one, allows for changes in the focus of supervision as the practitioner develops in their skills and identity.
2. Self-monitoring (The reflective practitioner)
By providing a template for the important areas to be considered in supervision, the triangle can be used as a trigger for the content of self-monitoring and self-supervision. However, the ability to reflect upon your work requires specific skills in observation, analysis and action planning, and it requires a good knowledge base, grounded in theory. Kolb (1988) described a Four Stage Model of Learning, which has been modified by Morrison (2001) to adapt to the clinical supervision setting. As part of the process of self-monitoring the health care practitioner may find it useful to:
(i) Reflect upon their experience of what has happened (this may be descriptive and objective)
(ii) Reflect upon their experience of what it was like (this may include feelings and thoughts which are subjective)
(iii)Analyse their experience in light of stage (i) and (ii), and in light of current research findings (the practitioner may wish to form a hypothesis from this experience; identify strengths and weaknesses)
(iv)Review their practice in light of stages one, two and three (this may involve planning a change in the approach to caring, or preparing further action; or establishing a baseline of good practice)
The health care practitioner may wish to refer back to the questions outlined within each cell, in the previous section 'issues within each cell'; the use of open questions will enhance reflection. Failure of the practitioner to complete this four-stage cycle of reflection may result in the loss of a good learning experience or the reinforcement of poor practice.
Exercise 2.1 Reflection activity
Identify a client, from a different cultural background to yourself, with whom you have recently been working. Imaging that you will need to discuss this client in your next supervision session.
-
Using the Supervision Triangle, identify the cells which you could prepare for discussion (for example, cultural assessment, communication, etc)
-
Identify the exact questions and issues relevant to this case, which you would want to explore with your supervisor.
Now answer the following questions:
- Did you find this task easy?
- Did the supervision triangle help you to focus upon issues for discussion?
- Which cells did you use?
- Will you be able to use the supervision triangle in practice?
Feedback your answers into a group discussion.
How was the issue of culture considered?
The intergrative development model
Another model of clinical supervision, relevant to transcultural health care practice, is the 'Integrative Development Model'. The Integrative Development Model (IDM) - as suggested by Stoltenberg et al (1998), is a good way of understanding the content and process of supervision. Basically, the model proposes a three-stage process, which it is suggested, parallels the developmental stages and competence of a supervisee.
The following diagram illustrates the three-stage process.
The model suggests the supervisees begin with a reliance on the supervisor (Stage one) and progress through a more exploratory phase (Stage two) to a position of autonomy (Stage three). At each of these stages, the supervisee has different needs, strengths and challenges. As with any stage model, it is possible to anticipate that a supervisee may be at different stages within the process in relation to different areas of professional competence. For example, a supervisee may be at different stages for different aspects of case management; he or she may be autonomous and competent in organising interviews and visits, but still in stage two when making judgements about prioritising workloads. This model, therefore, suggests that at different stages of supervisee training and development the supervisor has to attend to different needs and address different goals.
At all stages of the health care practitioner's professional development, and particularly when there may be little choice of flexibility about who supervises, the need for appropriate and quality supervision is paramount. Providing a model for good supervision in a multicultural context seems to be the first step.
Stage one: reliance upon the supervisor
The supervisor, at this stage, is in a position to influence the supervisee in his or her own values and beliefs, through the process of role modelling and through the establishment or determination of baseline standards in transcultural health care practice. Conflict can arise when there is little recognition of the ethnic and cultural differences that exist between clinical supervision participants, or between practitioners and clients
To promote the development of competence in transcultural health care practice both the supervisor and supervisee need to be aware of the cycle of destructive conflict, and to seek to avoid situations of conflict from arising or to resolve any unforeseen conflict in a constructive and positive manner.
Refer back to the cycles of destructive and constructive conflict in chapter one.
Also, refer to section one of the module Transcultural Communication and Health Care Practice regarding the importance of the recognition of your own cultural values and belief systems, and those of individuals with whom you work.
Stage two: The exploratory phase
During this stage the supervisee may have had the opportunity to develop a secure and trusting framework of support within clinical supervision. This is an important phase where the supervised practitioner may try new methods of health care practice, and explore different cultural perspectives and experiences; this is a move away from the security and familiarity of one's own cultural outlook. The participants of the clinical supervision session will need to be sensitive to this process; the exposure of 'incompetence' in knowledge or practice may result in a practitioner who feels vulnerable and 'blocked' in their professional development.
Refer to section three of Transcultural Health Care Practice: Foundation Module to examine the model of competence development by Purnell and Paulanka (1998).
Stage three: autonomy
At this stage the practitioner may experience autonomy in knowledge acquisition or skill. Although this stage of development raises the practitioner onto a different operative level within the clinical supervision setting, it is important to remember that learning is an activity that is ongoing and subject to the context within which the individual works; and the health environment, and health care practice, is continuously developing.
Conclusion
The question posed at the start of this module was "What should I actually DO in supervision?" The response is that supervisors' perquisites are knowledge of context, an appropriate theoretical model of supervision, and skills in effective intervention strategies. Armed with such knowledge and skills, the supervisor can then take a copy of the Supervision Triangle to sessions and use it (following appropriate modification) as a template for goal-setting, case discussion, evaluation and review.