Abstract
Clinical supervision is a very important component of psychiatric training. For the trainee, formal supervision process presents an opportunity to develop an understanding of psychopathology and the theoretical underpinnings of therapeutic interventions in addition to the acquisition of clinical skills. During this time the supervisor acts as a clinical role model, teacher and examiner, administrator and often the trainee's manager within the mental health service. The supervisor also models for the trainee the personalsocial components of clinical practice, such as professional and ethical standards of conduct and the management of work-related tensions.
The formal supervision process generally comes to an end upon obtaining Fellowship of the College, and in the past supervision has not been considered integral to the professional practice of the psychiatrist, other than for those who may go on to further training in psychotherapy. However, there has been a fundamental shift in the philosophy of professional education and training resulting in the expectation that ongoing learning and refinement of professional skills is instrumental to safe and ethical practice. Further, professional supervision, in the context of review with peers and/or senior clinicians is considered to be a mechanism for the promotion of the objectives of continuous professional development.
This position is reinforced by social pressures which encourage the legal and economic accountability of all health professionals, coupled with the increasing awareness of the deleterious effects of work-related stress on the worker's health and work practices. For these reasons, professional bodies such as the College encourage supervision as a component of continuous professional development.
Supervision is defined as the ‘promotion of supervisee development or maintenance of clinical skills by a more experienced or designated clinician or by peer supervisors, that is colleagues with similar training or experience’ [1]. Clinical supervision is one component of the complex task of continual professional development.
The objectives and form of the supervision process will vary according to the supervisee's level of professional development, therapeutic orientation [2], organisational structure, and the requirements of the professional body. Hawkins & Shohet [3] identified three processes or roles of supervision:
educative/formative – development of clinicians' technical and interpersonal skills and understanding supportive/restorative – a forum for the examination and management of the effects of practice on the clinician managerial/normative – quality control, to ensure that work practice is appropriate and falls within defined ethical standards. In most cases, the supervision of qualified professionals involves less emphasis on the acquisition of new skills than is the case during training. For the qualified psychiatrist the emphasis in supervision is on refining and honing clinical skills that will lead to more effective management of patients and resources, as well as an opportunity to develop collegiality and peer support [2,3].
Attending supervision is not without cost both to the individual clinician and the professional body that endorses them, and while it is generally accepted that supervision is beneficial, the question as to whether it has an impact on professional practice and patient outcomes is important. Therefore, the objective of this paper is to review the published research evidence on the value of supervision in relation to its effect on the quality and effectiveness of the clinical practice of the qualified practitioners receiving clinical supervision, in either an individual or group setting.
In the USA, the process of reflection on the effectiveness of the clinical practice of health professionals has previously been a retrospective, involuntary and externally motivated activity, designed to address the cost containment objectives of third party funders rather than the professional development of the clinician whose practice is reviewed.
When motivated from within the profession however, the objectives and process of peer review [4], overlap with those of peer supervision. About half of the College Fellows, currently enrolled in the MOPS programme are currently involved in some sort of peer review activity. All College Fellows have recently been sent a postal survey to clarify the extent and nature of peer review participation by College Fellowship (Robertson, 1998 personal communication). Robertson and colleagues [5] have previously described the nature of peer review activities members of the RANZCP engage in. These activities often reflect a peer supervision model, therefore, this review also examines the influence of peer review on the quality and effectiveness of the clinical practice of the psychiatrist.
REVIEW STRATEGY
A computerised literature search was conducted using Medline: (1966–1997); Psychinfo:1983–November 1998) and Expanded Academic Index. A preliminary search of psychiatry-related sites on the internet was also undertaken. Additional articles were identified from previous reviews. Articles were screened for inclusion on the basis of meeting the following inclusion-exclusion criteria:
The article had to meet the definitions of supervision or peer review outlined previously. Only original research papers were included for review. Included articles also took as a major focus one or more of the following key word fields: psychiatry, mental health, quality (quality assurance), education, professional development, costing/economics, (patient) outcomes.
Papers with supervision process or student/training foci were excluded from the review. The literature on the effectiveness of supervision in the training of psychiatrists is limited and has been reviewed elsewhere [6].
REVIEW
Most of the available supervision literature discussed the process of supervision with reference to specific theoretical and therapeutic orientations, such as psychotherapy. Fundamental to these descriptive papers were suggestions that link the supervision process to improvements in the clinical functioning of the supervisee, these assertions, however, lack empirical support. This literature has recently been reviewed [7].
Only the following five publications that presented data on the influence of clinical supervision/peer review on the psychiatrist's skills and knowledge, the process of treatment or the outcome of treatment.
Peer supervision was evaluated using a qualitative design by Balla et al. [8]. They examined the impact of participation in group peer review on the practice of 42 members of the psychotherapy section and child faculty of the Victorian Branch of the RANZCP who had been attending peer review for up to two years. Using a semistructured interview, the authors interviewed 42 Fellows in their eight review groups. A thematic analysis of the interviews was conducted, no quantitative analysis was reported. Participants acknowledged that participating in peer review did foster professional development through continuing education, constructive criticism and reflective practice, and through increasing awareness of professional standards. Subjects also reported that participation in peer review also reduced the sense of isolation and increased professional pride. These gains are intuitively, but not demonstratively, linked to improvements in clinical practice.
In 1994, NSW and Victorian members of the Psychotherapy Section of the RANZCP and the Victorian Faculty of Child and Adolescent Psychiatry were asked to complete a survey on their perceptions of aspects of the group peer review process [9]. One hundred and twenty-three of the participants in peer review groups (72%) and 67 non-participants responded to the survey. This paper basically provides a description of the nature of the supervision process, however, several findings are pertinent to this review:
Peer review groups comprising five to six members were perceived to provide more support and greater accountability than larger or smaller groups.
Groups meeting frequently (>20 times a year) tended to be thought of as providing the greatest support, educational gains and benefits to psychiatric practice. In terms of subjective gains:
73% of the respondents participating in peer review thought the process was of considerable benefit to their psychiatric practice.
70% thought peer review was of considerable educational benefit.
72% saw peer review as a considerable source of professional support.
While these reports of improvement in clinical knowledge and perceived support is acknowledged, it is not clear to what extent these gains lead to an actual improvement in clinical practice or care.
Given that the American model of peer review has been operating for twenty years, the lack of published investigation into the long and short term outcomes of treatment conducted under peer review is disappointing. The focus of the American peer review system may be more normative/regulatory (economic) than our own, but the components of reflective practice, and continual professional development are common to both systems. The following three studies examine the effect of peer review on the process and outcomes of psychiatric treatment in the USA.
A peer review system was established to monitor the prescription of psychotropic medication by psychiatrists in a large urban Community Mental Health Centre [10]. The intramural peer review procedure comprised regular meetings of a medication review committee that fed back to a monthly meeting of the medical director and psychiatric staff. During this conference prescription summaries were reviewed, with reference to the relevance to diagnosis and the treatment of target symptoms. The conference also provided a forum for the discussion of current psychopharmacology literature.
The comparison of prescription habits during two, twomonth periods before and after the establishment of the peer review showed a significant drop in polypharmacy and the inappropriate use of antiparkinsonian medications. The authors also report gains in clinicians' knowledge and prescribing skills, and enthusiasm for continuing education activities.
Sateria et al. [11] examined ways to increase the quality of the treatment of psychiatric patients presenting to the emergency rooms of two New England Hospitals. The quality of treatment of 2231 psychiatric emergencies by 16 emergency room physicians were evaluated according to complicated ‘quality assurance’ practices. Half of the physicians received individual, ‘interactive’, case feed-back sessions with the psychiatrist (which appeared to be a type of individual supervision with a more evaluative focus), the other half did not have extra contact with the psychiatrist.
The authors report that the results of this pilot study indicate improved clinician performance relative to explicit criteria, in response to the feed-back session. The performance of the physicians who did not engage in case review with the psychiatrist did not change over time.
As with many of these American studies with a quality assurance focus, the point argued is political rather than a scientific, consequently, the presentation of statistical support for the authors' assertion is inadequate.
There has been one randomised control study of the effects of peer review on patient outcomes [12,13]. The outcomes of two groups of community mental-health patients with chronic mental health problems whose care had or had not been the subject of peer review were examined. The multidisciplinary, intramural peer review committee of this Californian Hospital's community mental health centre met weekly to review and authorise the treatment of publicly funded patients. The objectives of this review committee were to identify treatment options most beneficial to the patient and reduce unnecessary service utilisation by this group of high service users.
Fifteen pairs of patients, matched by diagnosis, inpatient days in the previous year and cost of mental health billings, were randomised to case review by the peer-review committee or to a non-reviewed comparison group. Patients, reviewers and therapists were apparently unaware of the conduct of the study. No differences in clinical outcome or utilisation of services between the two groups were found in the six months following peer-review [12]. The small sample size and the chronicity of the patients (a population with whom health gains are difficult to measure) could explain the lack of statistically significant effect in this study.
This study does highlight the difficulty in assessing the efficacy of clinical practice in terms of patient outcome. The relative importance of clinician/treatment variables in determining patient outcome, or later service utilisation is not clear. Further, the dependent variables of interest when assessing patient outcome will necessarily vary between populations. Evaluating the outcomes of treatment in terms of change in global health status or service utilisation may not be a reasonable expectation when one's study group comprises ‘long term psychiatric patients’. More subtle (and difficult to assess) facets of health status such as patients' understanding, compliance with treatment or other changes in behaviour will also contribute to patient outcome in some populations.
CONCLUSIONS
There are inherent difficulties in examining the quality and effectiveness of clinical practice, which have been discussed at length by others [5,14,15]. Changes in scientific knowledge and community values over time, the definition of quality according to extrinsic or intrinsic criteria, and the decision to weigh patient outcome (variously defined), or cost containment over the improvement or a profession's skill base, make definitions of ‘quality and efficacy’ of care shifting goal posts. Conducting scientific research into ways to improve the quality of such a complex human endeavour, then, is a very difficult task.
Supervision is demonstrably an effective training tool, and is therefore considered to be a central mechanism for the continual learning and professional development of the clinician as well as an important source of professional support and regulation. We also assume that engaging in supervision improves or maintains the skills of qualified professionals, and therefore affects the quality of the care that they offer. At this stage, however, there is little empirical evidence to support the supposition that the educative, supportive or normative functions of the supervision process actually translate to improved patient care or health outcomes.
Participation in peer review/supervision is an expensive and time consuming exercise [16], whose beneficial effects for the clinician and their patients have not yet been thoroughly investigated. In order to gain evidence on the effectiveness of the practice of supervision within the RANZCP, it would seem that supporting the conduct of research which is sensitive to change in the supervised psychiatrist's knowledge, technical and interpersonal performance, as well as patient health status and outcomes is an important adjunct to the MOPS endorsement of participation in individual or group peer supervision.