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Clinical supervision in the provision of intensive home visiting by health visitors.

Introduction

The development of practitioners who can be both reflective and critical is central to the delivery of effective health and social services (Thompson and Thompson, 2008). This is particularly important where practitioners are involved in child protection work (Ruch, 2005).

A recent review of what works with families where there are significant concerns about a child being at risk of harm emphasised the need for highly skilled clinical supervision to provide practitioners with space for reflective functioning and to obtain additional insights into the work they do (Thoburn et al, 2009).

This paper aims to show that the organisational context and theoretical framework that inform clinical supervision are important factors in ensuring practitioners in child protection are able to work in a reflective way.

Child protection and critical thinking

Child protection work is highly stressful and good-quality clinical supervision has been considered important in supporting the emotional wellbeing of practitioners. Clinical supervision enables frontline staff to cope with the stress and anxiety generated by their work, alongside the need for workers to 'feel free to express their fears openly and with the confidence that they will be supported, without fear of such admissions being seen as not coping' (Burton, 2009: 10).

Clinical supervision is also one of the key mechanisms for developing clinicians who are both reflective and critical. Recent reviews of critical cases suggest that 'effective and accessible supervision enables the critical thinking needed to understand cases holistically [and] complete analytical assessments. It helps practitioners to think, to explain and to understand' (Brandon et al, 2008: 105).

Organisational culture and models of clinical supervision

Considerable variation exists in the models and regularity of supervision practitioners working in the field of child protection receive, and there is often a lack of clarity of the role clinical supervision should play (Lister and Crisp, 2005). Previous research has found that the prevailing models of supervision were often 'task-focused' and 'instructional', with 'little evidence of learning via reflective practice' (Gibbs, 2001: 329).

Practitioners' perceptions of clinical supervision are often negative, and supervision is seen as being about 'doing wrong' or about 'not coping' rather than an opportunity for support, reflection and development (Lister and Crisp, 2005).

The organisational culture in which clinical supervision takes place also influences how it will be managed and accessed (Davys and Beddoe, 2010; Bond and Holland, 2010). Organisations that encourage experiential learning and development are more likely to support clinical supervision (Davys and Beddoe, 2010). However, if the organisation adopts an ethos that is preoccupied with blame and risk aversion, as often occurs in child protection services (Munro, 2004), clinical supervision can become little more than an opportunity for surveillance and risk management of practitioners (Bond and Holland, 2010).

Study aims

In January 2001, a new intensive home visiting service was established at 48 GP practices across two counties in south-east England (Barlow et al, 2003). The service comprised an innovative, primary care-based home visiting service aimed at the primary prevention of maltreatment, abuse and neglect, and the promotion of positive parenting and secure attachment (Barlow et al, 2003). The home visitors taking part in the programme were health visitors trained to work in partnership with high-risk parents (Davis et al, 2002) and to develop a relationship based on trust, empathy and respect (Barlow et al, 2003). It was recognised from the outset that this work could not be done without adequate support and good supervision.

This paper presents the findings of a study that aimed to explore the perceptions of home visitors about the impact of fortnightly clinical supervision sessions in enabling them to work effectively with families with complex needs.

Family Partnership Programme

The training of the home visitors and the model of supervision used in the home visiting study were based on the Family Partnership Programme (Davis et al, 2002), which recognises the need for a partnership between client and helper, or supervisor and supervisee. It aims to facilitate equality of power regarding decision-making in contrast to the 'expert' model, which gives priority to the views of the professional, with obvious implications for the client (Darling, 2000).

The development of the partnership relationship is a prerequisite for the next stages in the helping process, which includes an open and careful exploration of difficulties or concerns, establishing a clear view of the issues, goal setting, implementation of plans, and an evaluation of outcomes.

Clinical supervision

Supervision was intended to provide a confidential space to talk about difficult issues that sometimes personally affected the practitioners, as well as a space to feel safe enough to express their feelings, and to experience having difficult feelings understood.

Clinical supervision aimed not only to provide home visitors with the opportunity to discuss individual families and any concerns, but also to help them work in a more effective way using the partnership model. It aimed to promote the integrity of the delivery of the intervention and to ensure the ethos that informed the study and clinical supervision was being maintained. As such, clinical supervision was used to facilitate observation of the relationship between client and professional, and encourage the development of a partnership.

Group supervision with three to four home visitors was provided throughout the study for an hour and a half fortnightly, by two skilled, psychodynamically trained psychotherapists who had experience of working in child protection and infant mental health. The format for the supervision sessions was that each home visitor presented material about a particular clinical case, followed by a discussion.

Methods

Design

The study comprised a randomised, controlled trial (RCT) with an embedded qualitative component. This paper summarises the findings of the qualitative data, which explored the perceptions of home visitors about the impact of clinical supervision.

Sample

A purposive sample of home visitors was obtained (health visitors who were providing an intensive home visiting service to high risk families) as part of a home visiting study outlined above. Only those health visitors participating in the home visiting study and caring for women in the intervention arm (and thereby receiving clinical supervision) were invited to be interviewed.

Twenty home visitors were approached and 15 agreed to be interviewed. Both psychotherapists were involved in the supervision of those health visitors who agreed to be interviewed. All of the home visitors interviewed had previous or current experience of working with high-risk families. All the home visitors except one were employed on a full-time basis and the average years of experience for the group was 15 (range three to 23 years).

Data collection

Individual interviews were conducted with home visitors between June 2003 and 2004 in either the health centre where the home visitor was based or a room in the university--whichever was convenient to the home visitor. The overall aim of the interviews was to: (a) obtain a better understanding of home visitors' perceptions about the home visiting study; and (b) to explore some of the difficulties that home visitors experienced in the delivery of the service.

Data from unpublished previous group discussions with home visitors informed the topic guide used in the interviews. Clinical supervision was one of several topics explored during these interviews. Each interview lasted approximately one hour, was conducted by the first author, was audiotaped and transcribed verbatim.

Ethical considerations

Home visitors who had previously expressed an interest in taking part in the research were invited by letter to be interviewed and were asked to indicate their willingness to participate. Full ethical approval was obtained from the local research ethics committee and written informed consent was obtained before conducting the interviews. All data were anonymised using pseudonyms. The identity of research participants was known only to the research team.

Data analysis

Data were analysed using thematic analysis (Braun and Clarke, 2006). Organisation and management of the data were facilitated using NVivo software.

Findings

The health visitors' experiences of clinical supervision as part of the home visiting study were grouped under two main themes:

* Improvements to professional practice as a result of clinical supervision

* Advantages of receiving clinical supervision from a psychotherapist.

Improvements to professional practice as a result of clinical supervision

Many participants reported that their practice had been improved as a result of receiving fortnightly clinical supervision sessions. These were depicted as positive changes and comprised a number of dimensions as follows.

Maintenance of boundaries

Some home visitors reported that clinical supervision had better enabled them to establish and maintain professional boundaries with the families they were visiting. Home visitors suggested that it was sometimes difficult to assert themselves with families, especially when faced with difficult situations. Clinical supervision was perceived as helpful in the negotiation of ground rules, from which they and the family could work together in a more productive way:

'So just simple things like actually asking them to turn the television down or to turn the television off, you can feel quite intrusive doing that. Actually, it is their home and you are a guest and so it is helpful to actually know that there are certain ground rules that you can make.' (HV4) 864-72

Reflecting on practice

Participants also talked about having used supervision as a means of reflecting on their practice. For example, one home visitor commented:

... it's a great thing to be able to reflect on visits and to just get some ideas. Like this business about how do I approach a mother about talking about a baby being 'sexy' you know. I know it's not the correct thing to say, but I wasn't sure about how I would approach it and how I would talk about it in a way that the mother understood and without her being upset by it, and without it being too critical.' (HV1) 1215-221

Another reported that being openly reflective enabled her to obtain advice on the best practice to adopt.

'I just find it such an efficient way of working, to be able to reflect on what you have done and what is good and bad about it, and get some course of correction and for our supervisor to pick out things that were worthy of attention which I would just not necessarily assume significant.' (HV2) 974-77

Development of better understanding

Clinical supervision was also perceived as having encouraged home visitors to develop a better understanding of some of the issues with which these families were presenting. One home visitor reported that clinical supervision had allowed her the opportunity to gain more insight into some of the problems families were experiencing:

'... one of the babies that somebody was seeing had got eczema ... and the supervisor said, "Well, what does that mean to you?" So I said, "Well, she probably needs to change the washing powder or think about what's she's putting in the bath or, you know, think about irritation", so the supervisor said, "Sometimes there's the view that if baby's not psychologically contained, they break out!" I just thought that was fascinating and the idea that if babies are sick enough then they can be stressed ... all these subtle things that as a health visitor you're just not taught ...' (HV6) 777-91

Challenging practice

Related to the issue of reflection, home visitors described the way in which supervision had challenged some of their practices, suggesting that such challenge had heightened their self-awareness. They described how the supervisor had often asked them to explain the motives behind the professional decisions that they made:

'... it was quite challenging, you know, about things that you had discussed or hadn't managed to bring up, like missed appointments ... like, have you asked her what the meaning of her not being there was? ... have you tackled her about that missed appointment? Because normally I just put a card through the door and ring up and say oh, you know, "When shall I come again?" but never actually say, "Well, why weren't you there? What was all that about? Why weren't you there?"' (HV3) 1002-09

Another home visitor stated that it was sometimes easy to avoid confronting clients about certain behaviours. She provided an example where clinical supervision had encouraged her to look at the cause of one woman's behaviour and enable her to explore this more fully.

'... I think maybe the other great benefit of supervision is that it is very easy to back off from asking perhaps the difficult questions to the mother or asking, you know, "I notice you found this really difficult, can you tell me why?"' (HV5) 577-80

'... and the mother became so angry with me and sort of yelled at me [nervous laugh] that I became a bit taken aback. And it's thinking, "OK, do I ignore that or do I acknowledge?" and what words do I actually use to say, "I noticed last week that you became rather upset when I mentioned ... or you were cross with me ..."' (HV5) 596-604

Being challenged about practice, however, was not always a comfortable experience:

'Yes, it was challenging and at times I didn't like being challenged really.' (HV3) 996-97

Despite this, it did help one home visitor to think more deeply about what she was doing.

'Not very comfortable sometimes [clinical supervision], challenging ... but very useful because it really makes you think.' (HV4) 1020-21

'I wouldn't necessarily say very much in the supervision about it, but I would go away and think "um, why did I do that or why didn't I do that?"' (HV4) 1023-25

Opportunity to share experiences

One of the home visitors commented that although she did not feel she was learning anything new in clinical supervision, she enjoyed the support that the group offered:

'I like group supervision ... I actually prefer group supervision to individual supervision ... it was always very helpful and it was good to have your colleagues as well as [name of clinical supervisor] there to support you, to give you ideas ...' (HV3) 1018-21

Advantages of receiving clinical supervision from psychotherapist

Home visitors enjoyed receiving supervision from a psychotherapist and reported that her different knowledge base helped them consider alternative solutions to managing situations and obtain different insights into some of the problems families were experiencing. One health visitor commented:

'I really like supervision. [Name of clinical supervisor] was the supervisor that I've been seeing and I found, again, it was just so interesting having supervision from somebody who isn't a health visitor and has got a very different perspective on things.' (HV6) 768-71

Another home visitor referred to the specialist knowledge that was provided by the clinical supervisor and, in particular, the role this played in helping the practitioner to think about the link between the mother's own childhood and her relationship with her new baby:

'I mean she [clinical supervisor] has got a knowledge base that is quite different to mine.

She had a knowledge of relationships and psychology of the child, and what would be significant to mum from her own childhood experiences.... [and a] general knowledge of psychology and what behaviours on the part of the mother might signify. I found that really valuable: (HV2) 977-83

This expertise reflected the supervisors' background in the field of psychotherapy.

Discussion

The data from this study suggest that health visitors delivering an intensive home visiting programme and working over extended periods of time with high-risk families perceived themselves to have benefited in a number of important ways from receiving regular clinical supervision. These findings contrast with those of other studies (Gibbs, 2001; Lister and Crisp, 2005) in which child protection workers have been highly critical of the organisation and delivery of the supervision they received (Gibbs, 2001).

Home visitors perceived themselves as having been encouraged to challenge and reflect on their practice, and as a result of increasing self-awareness were able to examine and re-evaluate the clinical decisions they had made. This included, for example, examining the difficulties that the home visitors experienced in confronting women who repeatedly missed appointments and enabling them to understand why this was hard to do.

The home visitors also perceived supervision to have improved the service they provided and although it was not possible to provide objective evidence of a direct link between the supervision received and the quality of the service provided, a series of interviews conducted with women who participated in the study indicated that they perceived themselves to have made significant changes as a result of the home visiting service, both in terms of their mental health and parenting practices more generally (Kirkpatrick et al, 2007). Many of the participating women referred to the quality of the relationship with their home visitor as having played a significant role in helping them to achieve this (Kirkpatrick et al, 2007).

Home visitors talked about the benefits of receiving clinical supervision from someone with a different professional background and some appeared to particularly value the psychological insights resulting from the psychotherapeutic expertise of the supervisors. These findings support other research, which suggests that clinical supervisors who are external to the professional group bring additional advantages. They are less likely to accept assumptions held by the individual or group and are more likely to challenge decisions made about practice (Davys and Beddoe, 2010).

Other benefits of 'external' supervisors included the fact that clinical supervision focused on issues concerning clinical work rather than organisational or management issues. Home visitors also reported that supervision meetings were held regularly, regardless of what was happening in clinical practice. This is supported by other research, which suggests that clinical supervision facilitated by those external to the organisation is less likely to be cancelled or disrupted (Davys and Beddoe, 2010).

The findings from this study suggest that the success of clinical supervision depends upon the culture in which it is imbedded. The philosophy of care underpinning the supervision process (and the wider environment within which the supervision was located) was based on the Family Partnership Programme, a model of partnership working, which was aimed at promoting self-development through a culture of equality of power, empathy and respect, and where mistakes and problems were viewed as opportunities for learning. This is particularly pertinent in child protection, which often cultivates a culture of blame and where supervision can be used to monitor outcomes and performance rather than learn from problems (Gibbs, 2001; Davys and Beddoe, 2010).

Limitations

Although the data presented were collected between 2003 and 2004, the findings are still relevant. For example, a recent survey suggests that half of practitioners involved in child protection work believed access to clinical supervision was the same as before 2003, and more than a quarter believed access to supervision had become worse since that time (Hunter 2012). This was despite recommendations made concerning the importance of supervision for those working in child protection (Laming 2003; 2009).

In addition, Ruch (2007) suggests the supervisory model that predominates in child protection continues to emphasise management and monitoring of performance, rather than the provision of support. To date there has been no national model formulated for child protection clinical supervision (Botham, 2012) and the few studies that explore the perspectives of health professionals about clinical supervision provide little detail about what actually occurs in a supervisory session (Hall, 2007) or the model to which staff were being exposed (Wallbank and Woods, 2012).

Although the limited caseload held by the home visitors in this study enabled the participants to focus in some depth on the clients' problems, the model of supervision being implemented has relevance to wider health visiting practice, where health visitors may need to focus at a more superficial level on the problems being faced by a wider groups of clients.'

The limitations of the study include the small number of home visitors who were able to take part in an interview, and the fact that the supervision process was only a small part of the data collected. Also, the practitioners may be unrepresentative of other practitioners working with child protection issues, as result of their participation in a funded research project. In addition, only two therapists were involved in clinical supervision, so the findings may reflect their own individual style of supervision and not those generally used by other therapists or supervisors.

Implications and recommendations

High-quality clinical supervision is an important part of practice for those involved in frontline child protection. However, for practitioners to benefit, the organisational context in which supervision occurs must be supportive and the model of clinical supervision sufficiently challenging to allow for reflection on practice.

Conclusion

The results of this study suggest that health visitors working with high risk and vulnerable families valued the provision of regular supervision, and perceived it to have had a significant impact on their practice.

The factors identified as having contributed to the success of the supervision include the opportunities for reflection, the delivery of supervision by someone from a different professional background and the culture within which the process of supervision was embedded--in this case, a partnership model of working.

Key points

* Previous studies indicate child protection workers are highly critical of the organisation and delivery of the clinical supervision they have received. Clinical supervision often takes place in a culture of blame, where supervision is used to monitor outcomes and performance

* Despite a number of high profile reports outlining the importance of clinical supervision for practitioners working in frontline child protection, little has changed over the last decade with regards to the accessibility and organisation of clinical supervision

* Providing practitioners working in frontline child protection with the opportunity to obtain in-depth understanding about the motivations of both themselves and their clients, though high-quality clinical supervision is a key method of developing clinicians who can be both reflective and critical

* The findings of this study suggest that health visitors working with high-risk families perceived regular supervision to have had a significant impact on their practice. The model of clinical supervision used, the organisational culture in which supervision was provided, and the professional background of those who delivered the clinical supervision, were all perceived to be important factors in determining its success

No conflict of interest declared

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Patricia Jarrett MPhil BA(Hons) RN Midwife FHEA

Research Fellow, School of Health and Education, Middlesex University

Jane Barlow DPhil FFPH(Hon)

Professor of Public Health in the Early Years, University of Warwick

Correspondence: P.M.Jarrett@mdx.ac.uk
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Title Annotation:PROFESSIONAL AND RESEARCH: PEER REVIEWED
Author:Jarrett, Patricia; Barlow, Jane
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Feb 1, 2014
Words:4120
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