Rural and remote psychologists’ views on provisional psychologist supervision

ABSTRACT

Objective

South Australia’s rural and remote psychology workforce is experiencing shortages. However, in seeking to place provisional psychologists in rural settings, universities have found it difficult to recruit supervising psychologists. This study seeks to understand what rural and remote psychologists view as the barriers and facilitators of supervising provisional psychologists.

Method

A qualitative research methodology was used. Ten rural or remote psychologists participated in semi-structured interviews. Data were analysed using reflexive thematic analysis.

Results

Barriers and Facilitators were explained by participants, including three sub-themes to Facilitators not previously reported in the literature: Benefits, Ownership, and Motivation. All participants expressed altruistic motivations for supervision however factors such as the Medicare rebate rates, feelings of division within the profession of psychology, and confusion about required qualifications to supervise acted as deterrents to offering supervision. Differences were evident between supervision in public and private practice contexts.

Conclusions

The findings from this study warrant further exploration and action from the profession and government. Proposed solutions to the barriers identified include government funding for supervision, equalising the Medicare rebate items, and better promoting the benefits of supervising. This research offers novel insight into the views of rural psychologists on supervision and professional commitment more broadly.

Key Points

What is already known about this topic:

1. Rural and remote psychologists develop a unique set of context-based skills and knowledge.

2. There is a shortage of psychologists in rural and remote areas of Australia.

3. Universities struggle to place students in rural areas in part due to a shortage of psychologist supervisors.

What this topic adds:

1. Rural psychologists in private practice consider the prospect of supervision resource intensive and potentially disruptive to client care.

2. Non-Clinical Endorsed psychologists reported feelings of frustration and perceptions of inferiority tied to their lower Medicare item rebate and feedback received during the retirement of the 4 + 2 pathway.

3. The perceived messages of inferiority increased disengagement and reduced motivation to “give back” through provision of supervision.

In Australia, mental ill-health is a growing public health challenge and threat to economic prosperity. One estimate is that mental ill-health costs Australia $220 billion annually (Productivity Commission, 2020). Enhancing access to mental health services has become a key policy focus of governments and as skilled professionals with specialist, empirically demonstrated treatments and tools, psychologists form an integral component of Australia’s mental healthcare system (Australian Institute of Health and Welfare [AIHW], 2022c).

Rural demand for psychologists

“Better Access” to mental health services through Medicare was introduced in Australia in 2006, with the aim of improving equitable access to mental health services. The proportion of the Australian population accessing Medicare-subsidised mental healthcare from Clinical Psychologists doubled during the period 2009–10 to 2019–20 from 1.0% to 2.2% and increased for Other Psychologists (i.e., those with general registration and the eight other areas of practice endorsement, such as Health Psychology, Counselling Psychology and so on) from 1.8% to 2.9% (Australian Institute of Health and Welfare [AIHW], 2022a). Analysis of the uptake of Better Access to Mental Health Care MBS items, however, shows socioeconomic and geographic disparities in the use of these items, particularly with lower levels of uptake associated with increasing remoteness (Meadows et al., 2015). Consistent with this, as the national demand for psychological services has grown, the availability of psychologists has failed to keep pace (Enticott et al., 2022). As is the case for many other healthcare professions, the rural and remote workforce is experiencing more acute shortages than major cities, which has served to perpetuate longstanding inequities in rural health outcomes. In 2020, there were 31,618 psychologists working nationally but the distribution across regions was uneven, with 152 full-time equivalent (FTE) psychologists per 100,000 residents working in major cities, 91.5 FTEs in inner regional, 57.3 FTEs in outer regional, 47.2 FTEs in remote and 34.7 FTEs in very remote areas (Australian Institute of Health and Welfare [AIHW], 2022b).

Rural and remote residents comprise 28% of Australia’s population and live in areas that are diverse in both geography and community profile (Australian Institute of Health and Welfare [AIHW], 2022d). Rural and remote residents face unique mental health challenges that arise from the rural context, for example, suicide rates increase with each degree of remoteness (National Rural Health Alliance, 2021). Additionally, higher socioeconomic disadvantage, which is more prevalent in rural and remote areas, is associated with mental ill-health and risk of suicide (Enticott et al., 2022; National Rural Health Alliance, 2021).

Psychologist qualification pathways

The current shortage of psychologists is in part associated with the increase in demand for services, but also associated with the difficulties in increasing the rates of psychologists completing training. Although Australia has high numbers of psychology students enrolled in undergraduate degrees, this has not translated to increased numbers of postgraduate psychology students (Productivity Commission, 2020). Low postgraduate enrolments can be attributed in some part to low availability of supervisors to take students on placement, a compulsory component of all qualification pathways (Productivity Commission, 2020). Finding sufficient supervisors to provide placements for students can be a challenge generally but is especially difficult in rural and remote areas where psychologists are already stretched with high workloads and case complexity compared to their metropolitan peers (Varela et al., 2021).

As of 2023, two accreditation pathways to become a registered psychologist exist: five years of university training plus one year of placement under supervision (5 + 1 internship); or a six-year university pathway (a Master’s level qualification) that includes training in one or more areas of practice and placements under supervision, sometimes paired with a research degree (Australian Psychology Accreditation Council, 2019). Students who undertake placements under either pathway work as provisional psychologists until they satisfy the requirements of each pathway and seek registration. Graduates in the six-year university pathway can subsequently complete a further two-year registrar programme and obtain endorsement in one or more areas of practice (AoPE) that match their area of training, e.g., those completing a Master’s of Health Psychology can complete a further two years of supervision and training as a registrar to use the protected title of “Health Psychologist”.

Supervision in psychology

All pathways to become a registered psychologist require time spent working under supervision by a Board-approved supervisor who has met the Psychology Board of Australia standards (Psychology Board of Australia, 2018). Any psychologist who has held general registration for at least three years may apply to undertake supervision training. The training is competency-based and typically takes two or three days to complete through an accredited provider. The cost of these courses is typically an expense borne by the individual psychologist. Currently there is no Medicare rebate or other financial compensation available to psychologists for time spent training or supervising provisional psychologists, in contrast to some other professions, such as Medicine.

A Board-approved supervisor must apply to renew their supervisor status every five years (Psychology Board of Australia, 2018). Board-approved supervisors may supervise any provisional psychologist but the principal supervisors of “registrars in an area of practice must have held endorsement in that area of practice for at least two years” (Psychology Board of Australia, 2019). In the context of a rural and remote shortage of psychologists, the training requirements and supervision demands are important considerations when seeking to develop solutions to boost rural psychologist numbers.

The number of Board-approved supervisors has increased annually since a significant reduction occurred in 2018, reaching 22.3% of psychology registrants nationally in June 2022 (Psychology Board of Australia, 2022). At the same time, in South Australia 24.3% (n = 529) of registrants were supervisors but it is not known what proportion of those supervisors worked rurally and remotely (Psychology Board of Australia, 2022).

Approaches to boosting the rural workforce

Targeted training of rural psychologists to ensure they have the knowledge, skills and attitudes required to face the unique challenges of rural practice was identified by Sutherland and Chur-Hansen (2014) as important to rural practice success and is supported by international studies (Dyck & Hardy, 2013). Rural background is a common correlate of rural practice, as is having a spouse with a rural background (Dyck & Hardy, 2013; Wilson et al., 2009). Aiming to recruit students from rural backgrounds may help address workforce shortages if there are sufficient training opportunities in rural areas. Both strategies – recruiting rural students and sending students to the country – require a reliable supply of rural practitioners with Board-approved supervisor status who are willing to supervise. However, in seeking to implement such a rural placement strategy, university psychology departments in South Australia have found it difficult to source supervising rural psychologists, an experience also reported by Little et al. (2019).

Systematically sending students on rural placement has been implemented in Australia most commonly to address the shortage of general practitioners (GPs). This approach is supported by nationally consistent funding available to reimburse GP practices for the time doctors spend training and supervising, which is a model that could be considered to boost psychology supervisors (General Practice Supervisors Australia, 2022). Rural student placements have been reported to have a moderately positive impact on rural workforce recruitment in a small body of Australian and international literature, with some finding a 10% increase in the full-time equivalent rural workforce (Birden & Wilson, 2012; Brodribb et al., 2016; Wilson et al., 2009).

Barriers to rural supervision

The barriers encountered by rural psychologists impact their willingness and ability to supervise students and to deliver quality supervision experiences (Moore et al., 2010). The challenges reported in the literature include professional isolation (Productivity Commission, 2020; Roufeil, 2016); high workloads (Onnis & Pryce, 2016); complexity in rural practice that demands unique skills (Sutherland & Chur-Hansen, 2014); being chronically under-resourced (Eley & Baker, 2007); the unique ethical challenges that arise living in small communities (Sutherland et al., 2017); and, difficulty settling their families due to limited employment, schooling and housing options (Moore et al., 2010). Rural and remote practitioners require foundational skills across the breadth of professional psychology. Typically, there are limited or no specialist services in rural and remote areas, meaning that a rural placement can better equip graduates for the wide scope of rural work. In addition to the challenges of rural or remote practice, those wishing to become a Board-approved supervisor face barriers that their metropolitan-based peers do not. The high workloads and geographical isolation can make it more difficult for psychologists to attend professional development courses (Pelling & Butler, 2015; Shires et al., 2017).

Summary and research question

There is limited exploration of the difficulties and challenges of supervision from the point of view of Australian psychologists, and no research has been undertaken in the context of rural and remote healthcare settings. This research asks the question: What do rural and remote psychologists view as the barriers as well as the facilitators of provisional psychologist supervision?

Materials and methods

Participants

Ten psychologists were recruited to participate in semi-structured interviews conducted from January to February 2021. No incentives to participate were offered. Eligibility for the study included being a fully registered and practicing psychologist based in an inner regional, outer regional or remote area of South Australia as per the Australian Standard Geographic Classification (ASGC) system. Psychologists who worked at least part-time and those who worked fly-in/fly-out (FIFO) or drive-in/drive-out (DIDO) in regional communities were included. However, psychologists who both lived and worked rurally formed the majority of the sample.

Seventy-eight of the 90 psychologists who were approached via email, from a list compiled via publicly available information on the internet, did not respond. Of those who responded but declined to be involved in the study (n = 4), three were not supervisors who stated they felt they could not provide much value to the research. Eight psychologists accepted the invitation, and two further psychologists were referred for study participation by participants (snowball sampling), resulting in a total of ten participants.

Participants’ years of experience working as a registered psychologist ranged from 5 to 38 years (M = 17.7, SD = 10.4). Eight participants were female, two were male. Two participants had completed a doctorate degree, seven had completed a Master’s programme, and three had gained registration through the now-retired “4 + 2 pathway”. Six participants were Board-approved supervisors and five had previously supervised a provisional psychologist. Three of the psychologists described themselves as “experienced” in supervision and two were less so, with three years’ experience or less. Eight participants held one or two area of practice endorsements: Clinical Psychology (n = 6), Health Psychology (n = 1), Organisational Psychology (n = 1) and Clinical Neuropsychology (n = 1).

Seven participants worked in private health settings as either a sole trader, employee of a private practice or a practice owner. Three participants were employed in the public health sector. Only one of the participants had completed a rural or remote student placement themselves while studying.

Procedure

Ethics approval was granted through the University of Adelaide School of Psychology Human Research Ethics Sub-Committee (approval number H-2019-21/57). Potential participants were identified through public registers of psychologists practising in rural and remote areas of South Australia. Purposive sampling was undertaken to ensure a spread of demographic characteristics, including gender, qualification, region of practice and professional status. Participants were approached via email with an invitation to participate, information sheet and consent form. Where an email was not publicly listed, the interviewer made initial contact via telephone.

Information power was used to determine appropriate sample size. Information power is determined by examining five facets of information richness: the aim of the study; sample specificity; use of established theory; quality of dialogue; and analysis strategy (Malterud et al., 2016). For this research, the study aim was narrow, the target sample dense, the quality of dialogue captured was high and the analysis strategy did not include significant cross-comparison of cases, therefore the sample of 10 rural and remote psychologists was deemed sufficient to explore the research question.

The interviewer recorded the interviews and reviewed the transcripts for consistency with the recording and redacted identifying names and places. Following transcription, the transcripts were de-identified and stored securely and the recordings were deleted.

Interviews were conducted during January and February 2021 over Zoom and were recorded and transcribed by the Zoom programme. The transcripts were reviewed by the interviewer (the second author), for consistency with the recording, and identifying names and locations were redacted. Interviews ranged in duration from 21 to 55 minutes (average was 33 minutes). They were semi-structured and included open-ended questions that were flexible to account for whether the participant was a current supervisor or not. The interview questions were based on previous research about rural and remote psychologists’ experience with placements (Ostini et al., 2021; Roufeil, 2016; SA Health, 2021; Sutton et al., 2011). Questions included whether that participant had completed a rural or remote placement as part of their training; why they did, or did not, choose to engage in student supervision; whether they faced any issues in providing supervision; barriers and facilitators in the provision of supervision; plans for the future in relation to supervision; and past or current connection to educational (i.e., universities) and professional bodies in the context of supervision. The interviewer offered to provide the transcripts to participants to facilitate participant validation of the data. No participants took up this offer, but one participant sent some additional thoughts by email and these data were included in the analyses.

Analysis

The data were analysed by the first author using a semantic approach with reflexive inductive thematic analysis (Braun & Clarke, 2006, 2022). The first author is not a rural or remote resident nor a registered psychologist and approached this research as an informed outsider, with a four-year undergraduate degree in psychology. The second and fourth authors are Clinical psychologists, the third author is a Health psychologist. The second, third and fourth authors have experience with rural and remote psychology, though none are rural or remote practitioners. The third and fourth authors supervise and co-ordinate student placements for Health and Clinical trainees, respectively.

In keeping with qualitative methodology to enhance trustworthiness and rigour, the researchers kept an audit trail and reflexive journal during the interviews and analysis, which facilitated recording and reflection of thoughts for subsequent interrogation as analysis progressed and as themes and sub-themes were identified and altered throughout the analysis and write-up phases. The first author coded the data, and the second and third authors checked the codes against the audit trail, reflective journal, and the raw data. During the study design, interview, analysis and write-up stages, authors engaged in continuous discussions (logged in the audit trail and reflexive journal) and came to consensus regarding final codes and themes.

Results

The results are grouped under the overarching categories of Barriers and Facilitators. Barriers encapsulates the factors that participants cited as a hindrance to providing supervision. Facilitators were factors which participants believed made supervision more appealing or easier, with three novel themes identified: Benefits, Motivation and Ownership. Benefits were the personal, business and professional benefits participants saw in supervision; Motivation captured the strong feelings that participants expressed towards supervision and their profession; and Ownership reflects the varied perspectives of participants on the supervisor shortage problem.

Figure 1 outlines the key themes and sub-themes and Table 1 presents relevant participant quotes from the novel sub-themes. Many of the sub-themes identified under Barriers and some sub-themes of the Facilitators category have been previously identified and discussed in the existing literature. Known barriers to rural supervision include the burdens of professional isolation, high workloads, the large distances to be covered working in Australian regions, limited access to resources, the unique challenges of country practice and the attendant ethical dilemmas (Eley & Baker, 2007; Moore et al., 2010; Onnis & Pryce, 2016; Pelling & Butler, 2015; Productivity Commission, 2020; Roufeil, 2016; Sutherland & Chur-Hansen, 2014; Sutherland et al., 2017). The facilitating factors are often barrier reducing activities such as providing funding for student travel and accommodation and working in multidisciplinary teams (Roufeil, 2016). Similarly, the benefits of undertaking supervision have been studied previously, showing that rural and remote communities provide rich placement experiences for provisional psychologists (Little et al., 2019; Sutherland & Chur-Hansen, 2014; Sutherland et al., 2017).

Figure 1.

Concept map.

Table 1.

Themes and corresponding participant quotes.

Theme	Example quote
Benefits: Professional/workplace development	“The profession needs people who do placements, because otherwise we’re not going to have sufficient psychologists out there in the real world”. (Participant #5; Private practitioner)
	“I think it’s very, very good for the teams. I think that people tend to demonstrate their best practice […] supporting learning, offering mentoring […] able to share their learnings with students, […] it retains an emphasis on really high-quality healthcare when you’ve got that lens”. (Participant #3; Public practitioner)
	“Someone like me can get really stuck in a rut when […] we’re meant to actually stay really current so it’s an opportunity to, yeah, learn what what’s actually in university at this point in time”. (Participant #5; Private practitioner)
Benefits: Personal satisfaction	“I think I get personal satisfaction about sharing some of my knowledge [and] watching people develop helps me”. (Participant #5; Private practitioner)
Benefits: Student productivity	“But you’d also want to know that you could leave them for a bit otherwise your own caseload isn’t going to be addressed well. […] I have no idea how payment works with students, whether you get paid to have them and that sort of stuff, […] I guess you want to make sure you’re not taking a massive income loss”. (Participant #9; Private practitioner)
	“And if it’s a student on a placement, usually it means that the waiting list goes down because they’re independent enough in their practice that they’re seeing some of the consumers at the same time that I am, obviously still under supervision, but the later placement students are more independent” (Participant #7; Public practitioner)
Ownership	“And one of my goals for next year to really revitalise the student placement offering across country but there are some very ingrained systemic challenges to do that particularly around an incredible lack of workforce”. (Participant #3; Public practitioner)
	“Like in rural life doctors get money for having placements and that helps them have students and it’s all just part of their business. […] And we’re a different model but any profession, I mean OTs [occupational therapists] have to do placements, social workers have to do placements […] how [do] they manage to get those placements and what are their financial incentives and […] why does that work for them and not necessarily for us?” (Participant #5; Private practitioner)
Ownership: Work context	“Thirty per cent of my role was dedicated to providing clinical supervision […] so I had I had tons of capacity” (Participant #3; Public practitioner)
	“We’ve got clients powering through […] and we’ve got a diary and we’re making sure that our clients are sorted, meeting all the Medicare [and] AHPRA [Australian Health Practitioner Regulation Authority] requirements […] so that in some ways it’s about leaving time for the ability to make sure you have accommodated a student”. (Participant #5; Private practitioner)
	“I guess have lots of conversations with each other, around […] how we attract psychology to the country so that’s sort of partly what’s maintained kind of the relationship with the uni as well, and how we, I guess, continue that so that we can hopefully get a steady flow of students eventually”. (Participant #1; Public practitioner)
	“So for me, having a placement student is another way to help my community have greater access to mental health support, yeah. So, I think there can be huge benefits to both”. (Participant #8; Private practitioner)
Ownership: Responsibility	“I guess, maybe, hoping that the uni would […] approach and say, “what do you need to get this up and running” […] Because I figure unis that are looking to place students that’s kind of on them to have that offer, […] if you’re willing to take these students on either, here’s some remuneration for it, you’re not making an income, or here’s some resources you can have or probably things like, will pay for your supervisor training […] just that sort of stuff to make it a little bit appealing rather than 100% relying on our altruistic natures”. (Participant #9; Private practitioner)
	“Well, AHPRA [Australian Health Practitioner Regulation Authority] is not going to do it because they’re about keeping the public safe and that’s their core business, so they’re not, bluntly, they’re not interested in providing support to placements […] I think our current need is to actually talk to the government and get money for them (AHPRA) to be able to do that”. (Participant #5; Private practitioner)
	“It’s up to the individual practitioner or supervisor to work out, yeah, how about how about make that work in terms of the individual practice”. (Participant #10; Private practitioner)
Motivation: Professional discontent	“There’s now two tiers in psychology and […] my supervisor, although she began her Master’s was told she couldn’t be, the top tier recognises Master’s, so she had to do another 40 hours of supervision. Now, under sort of granny clause […] by the time she’d done that it was too late for me to apply for anything, so as far as the APS [Australian Psychology Society] was concerned, in terms of the tier, is I had not been supervised by a Master’s. It’s the most ludicrous thing because she was the same person. After, I said, “Have you learned anything after the 40 hours of supervision?” and she said no, so she now gets $40 more than me”. (Participant #2; Private practitioner)
	“I felt quite disillusioned because I reached out to one contact I was given at a university and, basically, I was struck off the list straightaway because I didn’t have, I wasn’t a clinical psych, disregarded straight off the cuff, which I thought, ah that’s a bit tough like I didn’t even have an inroad to chat”. (Participant #8; Private practitioner)
	“I also think that, for some of us, it’s also about feeling a bit inadequate […] when I talked to other people who’ve gone down four plus two pathway, really worked hard to have good knowledge base […] but still I think in the profession of psychology there’s a bit of a unfortunate, […] you can’t quite have the knowledge that other people have because you haven’t got that letter [Masters’s qualification] after your name, […] so I think that can be a barrier, […] that sense of maybe not being valued or people don’t value your perspective”. (Participant #5; Private practitioner)
	“I’d actually like to supervise […] I just didn’t feel a system facilitated it and […] I think it’s quite a lot of divisiveness created by that whole process [creation of the tiered rebate system] […] the APS says “Oh, you know we’re all together here”, but it seemed incredibly unfair […] there was quite a lot of it feeling bad, so um yeah, so I just basically had to hunker down and go on this is, this is the amount of money I’m working for, and I certainly didn’t feel inclined to extend myself, for the sake of students”. (Participant #3; Public practitioner)
Motivation: Altruism	“Not only am I getting to mentor the next generation but I’m also helping my community more by having more people to help”. (Participant #8; Private practitioner)
	“It is potentially a loss to the business but it’s also a big picture, a huge game”. (Participant #8; Private practitioner)
Barriers: System design and navigation	“I think anyone in private practice probably needs 12 months’ notice to have a conversation about what it looks like […] and then say yes, and then get the information”. (Participant # 5; Private practitioner)
	“We are frequently annoying the universities, because I didn’t adhere to the vet[ting] process because it didn’t work for country. So many of our students would nominate to do an intensive plan placement over the summer break, for example, which doesn’t fit with the UPAC timing allocations […] I think for every single student we ever talk [to] we established a customised arrangement based on their needs” (Participant #3; Public practitioner)
	“It [supervision] actually has a financial impact, but don’t tell my supervisees that because, unfortunately, people on the four plus two can’t earn money as provisional psychs, so that impacts on them too”. (Participant #5; Private practitioner)
	“I thought I couldn’t supervise because there’s been confusion about 4+2 pathways, so some of that’s AHPRA-based where I actually thought I didn’t have qualifications”. (Participant #5; Private practitioner)
	“I was told because I don’t have a clinical endorsement, I cannot be a primary supervisor, which made me feel very sad with all my experience and passion […] and I think I could be a secondary, but I didn’t even that didn’t even seem clear to me with when I spoke to the program coordinator”. (Participant #8; Private practitioner)

Benefits

The Benefits theme encapsulates what participants saw as beneficial about being a supervisor. There were three sub-themes. Differences arose under some Benefits sub-themes between public and privately employed participants’ perceptions of the benefits of supervising. For example, public health employees saw the student’s productivity as a benefit, while private practitioners cited the benefits of maintaining currency in their own skills and knowledge through supervision.

Participants who had supervised were able to articulate more specific benefits than those who had never supervised. Supervisors discussed the workforce development, team development, business development and recruitment benefits of supervision, while non-supervisors were more likely to cite general benefits such as enjoyment, personal satisfaction or sharing the beauty of country life.

Professional/workforce development

Participants talked about supervision being important to develop the workforce, to attract psychologists to work rurally, and to foster new talent for their business. Participants thought that being a rural supervisor had improved their own interprofessional collaboration, team development, and opportunity for intergenerational learning. This was more often reported as a benefit for those operating in a public health setting than those employed in private practice.

Participants who had supervised students in the past talked about the professional growth that supervision provided them personally, which included keeping their skills and knowledge current, expanding their professional learning and being motivated to self-reflect on their own practices and skills. Participants who were not supervisors also reported professional learning as an expected benefit of supervising students.

Personal satisfaction

This sub-theme identified the personal satisfaction and enjoyment that some psychologists gained from providing supervision. This sub-theme has strong links with the Altruism sub-theme under Motivation. The positive feeling that participants reported made them receptive to supervising again in the future and in this way could also be considered a motivating factor.

Student productivity

The potential financial burden of taking on supervision weighed heavily in the minds of private practitioners and business owners. Student productivity was the only potential counterbalance considered. For those working in the public sector, the potential to reduce client wait lists was seen as the primary benefit of having productive students under supervision.

Student productivity was linked to Facilitators, as a student’s suitability and readiness to undertake a rural placement determined if they were a productive addition to a practice and therefore of benefit to the supervising psychologist.

Ownership

This theme reflects the varied views and perspectives of participants that framed the “problem” of limited rural and remote supervisor availability. Participants shared varied beliefs about the supervisor shortage problem. Some believed the problem was a difficult one but were optimistic it could be solved. Others viewed the shortage of supervisors as similar to the placement challenges faced in medicine and other allied health professions and wondered why similar strategies hadn’t been implemented for psychology.

Work context

This sub-theme identified contextual factors regarding where and how a psychologist worked and how that influences their attitude towards supervision and to solving the problem of low supervisor numbers. Those working in public sector roles had supervision responsibilities built into their job specifications and often reported being engaged within their department leadership to advocate for increased student placements. On the other hand, those working as sole practitioners or who ran their own private practice prioritised other concerns, such as ensuring financial solvency and managing their client waitlist. These participants saw the benefits and importance of supervision but had more trouble balancing the potential costs with the rewards.

Those who had supervised in the public sector were overall more positive about supervision and the prospect of the supervisor shortage problem being solved. Their positive previous experiences of being a supervisor were a key factor that drove them to continue supervising or advocating for increased opportunity to supervise within their organisations. Private practitioners who had not supervised expressed optimism about the probability that rural supervision could help solve the problem of reduced mental healthcare access in the country.

Responsibility

Participants had varied opinions about who should be responsible for ensuring placement availability and bearing the burden of the costs of supervision. Most participants, regardless of employment type or supervisor status, had some sense that universities should have responsibility for setting up or bearing the burden of supervision. Some saw the government had a role to better fund the professional bodies to take responsibility for boosting placements. Others felt it was the responsibility of individual psychologists to figure out how to make it work for the betterment of their profession.

Motivation

This theme was generated from the strong feelings that participants expressed towards supervision and their profession that affected their motivation to supervise. Altruistic intentions drove many participants to supervise or consider supervising. However, some participants expressed strong professional discontent, which acted as a disincentive to supervise.

Professional discontent

For private practitioners, the tiered Medicare rebates for psychologists provoked feelings of annoyance, bitterness, unfairness, and a sense of professional division. Private practitioner participants who were registered psychologists or had a non-Clinical area of practice endorsement expressed disillusionment and bitterness that their skills weren’t recognised or valued as much as those of Clinical Psychologists, including as potential supervisors by universities. A participant talked about the perception of tiered skills recognition being widespread within psychology, especially for those who qualified under the 4 + 2 pathway, and how that can make them feel inadequate compared to their peers. Private practitioners also expressed feelings of having been neglected by universities or having had their talents overlooked due to not having the “right” qualification. This led them to not want to give back to the profession or to universities by offering supervision.

Altruism

This sub-theme has strong links to the personal satisfaction sub-theme in the Benefits theme as satisfaction promoted the desire to contribute to the profession by supervising. Both participants who had supervised and those who hadn’t held altruistic motivations for wanting to ensure the quality of training for the next generation of psychologists and wanting to “give back” to their profession. Participants who had not previously supervised expressed interest in supervising for the sake of the profession and wider community, although this desire was tempered by their personal and business interests.

Barriers

This encapsulates the factors that participants considered to be a hindrance to providing supervision. Many barriers under these sub-themes have been discussed in extant literature, but the sub-themes of system design and system navigation provided some novel insights to the supervisor shortage when considered alongside the Motivation and Ownership themes.

System design and navigation

This sub-theme encapsulates barriers that were identified in the systems that surround the psychology profession. This included processes for student placement, for becoming a supervisor, for housing allocation in rural areas, the overall workforce shortage of psychologists and the current Medicare rebate rates.

The student allocation process for university placements was described as challenging for psychologists. In South Australia the three universities (Adelaide, Flinders and South Australia) co-operate to match students with supervising psychologists through the University Placement Allocation Committee (UPAC), but private practitioners said they would like to have more time to prepare for placements. Meanwhile, public sector psychologists found it easier to arrange placements directly with the student, rather than through the established UPAC system, so they could create bespoke experiences that were mutually beneficial. Several private practitioner participants commented on the difficulty of making supervision cost-effective due to there being no Medicare rebate available for clients to see provisional psychologists, or for supervisors to charge for their supervising time.

Participants also reported encountering barriers trying to determine what was required to become a supervisor. Various bodies were mentioned as sources of information by those seeking to become supervisors, including the Australian Psychology Society (APS), Australian Health Practitioner Regulation Authority (AHPRA), and universities. One participant had contacted AHPRA to determine their eligibility and came away believing that they could not supervise due to their 4 + 2 qualification pathway (which is incorrect). Another participant had the experience of being turned away by a university because they did not hold the “correct” area of practice endorsement (under current accreditation requirements, a supervisor must be Board Approved, but otherwise, is eligible to supervise any provisionally registered trainee psychologist).

This confusion about eligibility to supervise and how to establish supervision is connected to the responsibility sub-theme under Ownership as it relates to who is, or should be, responsible for establishing placements.

Discussion

This research adds to the extant literature on the barriers to rural practice by offering findings on how personal and professional factors might be impacting on a psychologists’ motivation to supervise students on placement. Three facilitators were identified that have not been reported in previous literature: Benefits, Motivation and Ownership. The unifying theme that influenced and was influenced by all others was Motivation – participants who perceived the balance of professional working conditions favourably were positively motivated to supervise. Those who perceived the balance of conditions unfavourably were de-motivated despite displaying an underlying desire to supervise.

The Benefits theme captured what participants saw as beneficial about being a supervisor and supported the findings of previous research (Little et al., 2019). Psychologists who had supervised were more likely to talk about more tangible benefits, such as professional development, maintaining industry currency and workforce development while non-supervisors talked about more abstract benefits such as the enjoyment and personal satisfaction of supervising. This difference indicates that there may be knowledge gaps amongst psychologists about the tangible benefits that being a supervisor can confer. Providing more specific information about what supervisors can expect from the experience may encourage more rural psychologists to consider supervising. However, as articulated, whether a psychologist is working in a private or public context will impact their ability to do so, given that in public settings the role may be expected and remunerated, whereas private practitioners inevitably lose income.

For private practitioners, responsibility for supervision and its associated costs was seen as something that should be borne more heavily by the universities, the professional bodies or the government, rather than a responsibility for individual psychologists to grapple with. The sense that the burden of supervision has been left to individual psychologists constituted a perceived failure to provide support and, in this way, linked the Ownership theme with the Motivation theme due to the resultant expressions of professional discontent and low motivation to supervise.

Many of the barriers evident in the data reflected those rural psychologists have been documented to face; it seems reasonable that factors that make practice difficult might also inhibit supervision (Eley & Baker, 2007; Onnis & Pryce, 2016; Productivity Commission, 2020; Shires et al., 2017; Sutherland & Chur-Hansen, 2014; Sutherland et al., 2017). The sub-theme of system navigation and design was a novel finding not previously reported in the literature and was linked to both the ownership psychologists took over the problem and their motivation to become supervisors. Participants encountered difficulty navigating the system to become a supervisor and demonstrated misapprehensions about how supervision worked or reported that they had been turned away by universities when they reached out to enquire.

Both private and public practitioners who had supervised previously cited the student allocation process as a barrier, but for different reasons. Public psychologists reported that the University Placement Allocation Committee (UPAC) placement timings did not work so they had taken it upon themselves to negotiate an arrangement that would work for both their service and students. Student participants in Little et al. (2019) confirmed this practice, overwhelmingly reporting that they had arranged their own rural placements. Private practitioners faced different challenges, saying the allocation system provided insufficient time for them to prepare to manage their existing waitlist and their own reduced capacity while providing supervision. These findings suggests that enthusiasm to supervise could be supported by increasing flexibility in the allocation processes. The concerns about reduced productivity might also be alleviated by providing reimbursement for time spent supervising, although that would not address concerns about clients waiting to be seen.

In addition to trouble navigating the system, participants expressed dissatisfaction with the way the system compensated and recognised psychologists. Private practitioners lamented the absence of any reimbursement or Medicare rebate for supervising psychologists or for provisional psychologists seeing clients independently. This echoes the findings of a survey of NSW psychologists (Shires et al., 2017). Although participants saw the benefit that having a productive provisional psychologist in their practice could offer, the inability to bill to Medicare presented a financial loss for practices and deterred some private practitioners from taking on students. The lack of recognition of a supervising psychologist’s investment of time and lost productivity contributed to not only decreased motivation to supervise but also seemed to reinforce a broader conceptualisation of the profession as unsupportive or dismissive of their valuable contribution.

Prior to June 2022 there was a third accreditation pathway available known as the 4 + 2 internship (Grenyer & Phillips, 2018). This entailed four years of university study followed by two years working under the supervision of a registered psychologist. This pathway was attractive to students wanting a rural career, in part due to the barriers faced by them in accessing university training programmes based in cities. Psychologists who completed this pathway were not eligible to obtain endorsement in an AoPE without completing a Master’s programme. Understanding the AoPEs is important to this research because clients of Clinical Psychologists attract a higher Medicare rebate than all other AoPEs and registered psychologists without an endorsement (Department of Health and Aged Care, 2022) – the “two-tier” system (Davis McCabe et al., 2019). This higher rebate allows Clinical Psychologists working as private practitioners to earn more if they choose to bulk bill, and to charge more per session in total before a higher gap fee is incurred by clients, which arguably, increases their overall earning potential compared to other psychologists.

Altruism was a motivator behind both supervision activity and intention to supervise. Private practitioner participants who were not Clinical Psychologists contributed most of the negative sentiment towards the idea of supervising students. Feelings of frustration, bitterness and annoyance, inferiority and lack of professional recognition arose from two areas: first, the two-tiered Medicare system; second, a sense that the profession views those who qualified under the 4 + 2 pathway as second-rate psychologists.

In terms of the two-tiered Medicare rebate, the lower reimbursement for non-clinical psychologists has been interpreted as a “message of value” that they are less qualified than their clinical psychologist peers, despite having undertaken equivalent, or more, years of study (Littlefield & Giese, 2008). This artificial hierarchy created by the Medicare rebates seems to have undermined the self-esteem and perception of professional support in non-clinical psychologists. The resultant feelings of imposed inferiority and bitterness are weighed heavily by the rural psychologists in this study who feel they are asked to take on the above-described burdens of supervision for little reward save personal satisfaction.

Implications

The data show that the barriers and facilitators of rural and remote psychology supervision are myriad, inter-related and context dependent. One factor that unifies the main themes is how the psychologist feels about their role within the broader psychology profession, reflected in the contrasting attitudes of resentment and positivity expressed under the Motivation theme. Any proposed solution to the rural supervisor shortage must acknowledge and address the attitudes of psychologists towards their profession.

The experiences of 4 + 2-qualified psychologists are important to understand because they still comprise a substantial proportion of registered psychologists. As at 30 June 2022, there were 3,370 provisional registrants undertaking the 4 + 2 pathway, 42.4% of all registrants (Psychology Board of Australia, 2022). If the divisive experiences and attitudes that were shared by the 4 + 2 participants of this research can be generalised more broadly, it would signify a risk of ongoing professional alienation amongst the current and immediate future psychology workforce. As has been argued by the Australian Association of Psychologists Inc (AAPi), consideration should be given to removing the two-tiered Medicare rebates in recognition of the equally valuable services all psychology areas of practice provide and the expertise registered psychologists develop in their APAC-accredited pathway to qualification.

The data collected in this research indicated that rural public and private practitioners have quite different experiences; this suggests that different strategies may be required to boost rural supervisor numbers in each sector. It may be useful to explore how the positive experiences in each employment type might mitigate the barriers presented in the other. A dual-employment model in public and private settings such as those seen in medicine and trialled in physiotherapy may have utility as a way to boost rural supervisor numbers (Schmidt & Dmytryk, 2014; Scott et al., 2020).

The encouraging finding in this study has been that psychologists see the benefits of supervising students and are willing to do so if the conditions are favourable. Providing systemic issues are addressed, it appears that there may be scope to grow student placements. Psychologists who have supervised reported more tangible benefits than those who haven’t, suggesting that an education campaign to highlight the business and professional development benefits and positive experiences of supervisors may promote interest. Developing how-to guides that show private practitioners how to navigate the productivity challenges of supervision may prove fruitful and also improve perceptions of support from universities and professional bodies.

Models for recognising and reimbursing practitioners for supervision already exist in other healthcare professions, such as medicine, and could be applied to alleviate many of the time and work-load related barriers identified in this and previous research. The Australian Psychological Society (APS, 2022a, 2022b) has advocated for the Australian Government to address the supervisor shortage and workloads, including increasing Medicare rebates for clients; investing $5 million for an additional 3,500 supervisors and 6,000 placement psychologists in the next two years; and replicating GP regional relocation incentives for psychologists.

Removing structural inequities and investing in infrastructure and programmes to support psychology supervisors may improve the messages of value that psychologists are receiving from their profession. This research suggests that such actions could shift some psychologists’ perceptions of their altruism being taken advantage of and motivate greater investment in their profession via supervision.

Strengths and limitations

Literature on supervision from the perspective of psychologists is scarce. This research provided an opportunity for psychologists to voice their lived experience providing supervision in rural and remote settings. The thematic analysis facilitated the identification of the supervisor experience without reference to existing paradigms about what it is to supervise provisional psychologists. Our research demonstrates trustworthiness and rigour (Yardley, 2000) following Tracy’s (2010) eight criteria. We have considered a worthy topic; with rigour (rich data, an appropriate sample, clear description of data collection and analysis); with sincerity (explaining our professional backgrounds and positions in relation to the topic); with credibility (for example, by presenting quotations from interviews); with resonance (the findings make sense, and are transferable); making a significant contribution (the findings are novel and have important implications); we have been ethical (remaining true to participants’ accounts and ensuring their confidentiality is maintained); with meaningful coherence (we have placed the findings in the context of current literature and knowledge, and we have achieved the goals and aims of the research, as stated).

The few psychologists who replied to decline the invitation due to not being supervisors suggests that there may have been response bias towards those who had supervision experience. The higher representation of private practitioners (n = 7) is noted; the data collected indicated that public and private practitioners operate in quite different contexts and as a result face different supervision challenges. Further research is indicated to understand these differences and any opportunities to improve supervision offerings and experiences in these different roles.

This study was based on South Australia and experiences may differ in different regions of Australia. It would be advantageous to include more psychologists working in remote areas in future research. It is also essential to garner the experiences and views of psychologists working in cities and urban areas, to determine the barriers and facilitators they face in the provision of supervision.

Conclusion

The facilitators of rural and remote supervision extend beyond removing structural barriers such as lack of time and confusion about how to become a Board-approved supervisor. Rather, a deeper examination of the perceptions of a lack of support from the professional bodies is implicated, especially in the case of private practitioners. Further, a review of the psychology services Medicare rebate items may reduce financial loss and increase professional self-esteem associated with providing supervision and as a result, increase motivation to supervise, particularly in private practice settings. Consistent with the conclusions of Barrett et al. (2020) further research is warranted into the experiences of supervision, including the evidence base for training, from all stakeholder perspectives.

Funding Statement

The work was supported by the SA Health Research Partnerships Small Grant Scheme [2020/2021].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The raw data cannot be shared, due to confidentiality for participants.