Examination of perspectives on CS through theoretical models

The theoretical models of CS are numerous today (see e.g. Faugier and Butterworth 1993, Fowler 1996a, van Ooijen 2000). However, several of the models presented have been borrowed and applied from other professional disciplines such as psychotherapy and counselling (Fowler 1996a), but it is also evident that during the 1990s an increasing number of authors have introduced models of CS for nursing (see e.g. Proctor 1986, 1991, 2000, Faugier 1992, Johns 1993, Friedman and Marr 1995, Severinsson 1995, 2001, Paunonen 1999).

In order to present an overview of the models and to show the different theoretical perspectives on the concept of CS some authors (Faugier and Butterworth 1993, Farrington 1995b, Cutcliffe and Epling 1997, Bernard and Goodyear 1998) have approached the models through categorisation. Faugier and Butterworth (1993) have found that the CS models fall into three major categories: (1) those describing CS in

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relation to the supervisory relationship and its main constitutes; (2) those describing the main functions or role of supervision and (3) developmental models that emphasise the process of supervisory relationship.

Farrington (1995b) has suggested that the CS models can be categorised into (a) client centred (b) triadic, (c) multicultural, (d) interactive and (e) growth and support models. Cutcliffe and Epling (1997) have argued that there are four central rudiments that are present to a greater or lesser extent in each of the CS models.

Based on this idea the authors make a loose classification into (1) supportive and enabling, (2) developmental, (3) client centred and (4) ‘staff investing’ models. Bernard and Goodyear (1998) have suggested a categorisation of the models based on that used in mental health and counselling such as (1) psychotherapy theory based models, (2) developmental models, (3) social-role supervision models and (4) eclectic and integration models. To sum up, the categorisations and their basis seem to vary from a pragmatic emphasis on the nature, core essence and functions of CS to theoretical perspectives with the emphasis on different disciplines and their combinations. What can be extrapolated from the literature, is also a general consensus concerning the perspectives that are deemed to be important and the interrelations between them.

This means that the models address at least four broad theoretical perspectives on the concept of CS by emphasising development, functions of CS in practice and supervisory relationship, including a client/patient relationship within a model. These are examined next more specifically focusing on the models of CS presented or cited and applied frequently in nursing.

Developmental models

Faugier’s (1992) model is one of the most cited ‘growth and support’ models in the nursing literature. The model focuses on supervisee’s ‘growth and development’ both educationally and personally whilst supervisor’s role is seen to ‘facilitate growth’ and provide essential support to the practice of clinical excellence. The key characteristics underpinning the ‘growth and support model’ are as follows: generosity, rewarding, openness, willingness to learn, thoughtful and thought provoking, humanity, sensitivity, uncompromising, personal, practical, orientation, relationship and trust. Friedman and Marr’s (1995) model shares a similar perspective with Faugire’s (1992) model concerning the emphasis on development, but a clear difference is in its focus on competence. The model aims at setting standards for clinical competence through integrating educational and professional systems by linking relevant education to skills and competencies required in clinical practice and facilitating professional development through a practitioner’s whole career. Friedman and Marr (1995) also stress the supervisor’s facilitating role and this is expressed as a linkage between CS and the concepts of ‘support’, ‘empowerment’ and ‘development’.

Models focusing on CS’s functions in practice

Proctor (1986, see also Proctor 1991) has suggested a three function interactive model for CS that is widely cited in today’s nursing literature. The three interactive functions in the model are termed ‘formative’,

‘restorative’ and ‘normative’. The formative function of CS is defined as its educational characteristic and linked to developing skills, understanding and abilities. This is achieved through reflection on, and exploration of, supervisee’s work. The restorative function is defined as supportive actions and responses to unload stress, but also to maintain adequate emotions, stability and boundaries by becoming aware of the

effects of emotional stress and of how to deal with any reactions. The normative function is defined as a managerial aspect of CS, as a crucial quality control element but also as crucial for developing standards.

Proctor’s (1986) model combines all three functions of CS and describes how CS can focus predominantly on one or the other functions at different times. However, it is pointed out that the functions are inter-related and overlapping. Paunonen’s (1999) model differs slightly from Proctor’s as it focuses on quality assurance in health care services. The model has an interesting similarity with Friedman and Marr’s (1995) model as it also suggests integration of CS, in-service training and further education arguing that this is beneficial to supporting and promoting nursing practitioners’ professional development as a continuous process. The model aims at defining the standards of quality in practice, but also at specifying practitioners’ expertise and challenges to professional development. The model emphasises that personal involvement improves motivation and commitment to develop unit’s clinical practice. The model is based on an assumption that in the long run this process will have a beneficial effect on quality of services and health care practitioners’

wellbeing.

Models of supervisory relationship

Heron (1990) has presented a six-category intervention style model, originally developed for counselling and professional training for counsellors, which has recently been adopted in nursing and applied by several authors (see e.g. Farrington 1995b, Cutcliffe and Epling 1997). The model is focused on the supervisory relationship and its different styles. In Heron’s (1990) model, equal value is placed on each of the six intervention styles. It is assumed that these can be used interchangeably or in combination at any point in supervision. The six styles are classified into two broader intervention styles: authoritative and facilitative.

The authoritative style is concerned with assertive styles in the supervisor’s on supervisee’s actions and practice. The authoritative style is composed of prescriptive, informative and confronting interventions.

Prescriptive intervention involves giving advice directly and directing supervisee’s behaviour explicitly.

Informative intervention seeks to instruct, impart knowledge and inform supervisee. Confronting intervention is concerned with being up-front with supervisee, giving clear, direct feedback and challenging beliefs and attitudes. Facilitative style is defined as a less directive one, eliciting information about supervisee. It consists of cathartic, catalytic and supportive interventions. Cathartic intervention means that supervisor attempts to enable supervisee to release tension and emotions, e.g. grief and anger. Catalytic intervention encourages supervisee to be reflective, self-directive and resourceful. Supportive intervention means that supervisor aims to confirm and validate the value and worth of supervisee. Cathartic and supportive interventions seem to be close to what Proctor (1986) has described as being the restorative function of CS. Interesting similarities exist between the definition of catalytic intervention and Severinsson’s definition of the characteristics of the CS process.

Severinsson’s (1995, 2001) model of CS is one of the newly published models in nursing focusing on supervisory relationship. The emphasis of CS is defined as support for the development of supervisee’s job identity, competence, skills and ethics. The model is based on an assumption that during CS the supervisor transforms knowledge on different levels by inviting a supervisee to begin and participate in a dialogue. An essential element in the model is the dialogue that is defined as dialectic for the purpose of

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understanding and explaining various phenomena in practice. The dialogue is important in order to receive and give (1) confirmation and gain insights. Confirmation is seen to have supportive and motivating, but also closeness promoting functions in relation to patients. According to the model, knowledge of and values concerning caring are transformed and learned during the CS process. This is conceptualised in the model as (2) giving a ‘meaning’. The second assumption in the model is that the CS process is largely a learning process in which growth and development take place, especially in the form of spiritual and emotional development. The third concept in the model is (3) self-awareness. It is seen that the dialectic dialogue starts the development process in which the active factor is self-awareness. To sum up Severinsson’s (1995, 2001) model: it integrates into CS three main concepts, which are confirmation, meaning and self-awareness. The model is interesting as it clearly emphasises supervisor’s competence and responsibility for establishing the key concepts in the nursing supervision process.

Models of CS integrated in patient care

Ekstein and Wallerstein’s (1972) model of supervision is interesting as it has been classified as one of the pioneering works (Bernard and Goodyear 1998) portraying and defining CS clearly as a teaching and learning process. It is argued that this model has distinguished CS explicitly from psychotherapy. The

‘rhombus’ model emphasises relationships describing them as mutual interaction and as processes of interplay among supervisor, supervisee/therapist, patient/client and administrator that constitute the processes of teaching and learning. The relationships are seen as stratification of the relationships, which also reflect the different functions and responsibilities that the participants carry. It is assumed in the model that the relationships confronted by supervisee are those with client/patient and supervisor and defined as

‘helping’ and ‘learning’ relationships. It is assumed that a supervisor has a quasi-indirect relationship to a client/patient as the main responsibility is teaching psychotherapeutic skills, but an additional responsibility consists of maintaining clinical and training standards. An administrator’s function is identified as being relevant to an extent that it provides insight into the aspects of the learning process and the employed teaching techniques. Ekstein and Wallerstein’s (1972) model is interesting because of its clearly defined educational perspective and indicated links of CS to the quality of practice and services.

Hawkins and Shohet (1996) developed their model originally for social work and other helping professions but it has been often cited and applied also in nursing (see e.g. Farrington 1995b, Cutcliffe and Epling 1997). The authors’ double matrix model has similarities with Ekstein and Wallerstein’s (1972) model in that it involves different professionals and emphasises the client relationship. The model turns the focus away from the context and wider organisational issues and looks more closely at the process of the supervisory relationship. Hawkins and Shohet’s (1996) model is based on an assumption that the different styles of supervision cannot be explained by developmental stages, primary task or intervention style. Instead it is assumed that the different styles of CS are connected to the constant choices and decisions that supervisors make about the focus in the tripartite relationship between supervisor, supervisee and client.

Based on these assumptions, the suggested model is composed of two interlocking systems or matrices.

These are (1) the therapy system (interconnecting supervisee and client) and (2) the supervision system (involving supervisee and supervisor). These two systems are further divided into six sub-categories

depending on the emphasis and focus of attention. This gives six modes of CS within an integrated model in which the therapy system deals with: (1) reflection on the content of therapy system, (2) exploration of strategies and interventions used by supervisee and (3) exploration of the therapy process and relationship.

The supervision system deals with (4) supervisee’s counter-transference, (5) supevisory relationship and (6) supervisor’s own counter-transference. The model is considered flexible and during the CS session movement between modes and adoption of several modes of CS can occur. The essential assumption in Hawkins and Shohet’s (1993) model is similar to Ekstein and Wallerstein’s (1972) in that identical parallel processes occur in therapy and in supervision.