ABSTRACT
Clinical supervision is claimed to benefit nurses' wellbeing, professional development and practice. However, evaluations highlight implementation challenges, and universal uptake among nurses is uncommon, which limits benefits and the quality of evaluations. This paper reports outcomes of a government policy initiative to implement clinical supervision in Victoria, Australia, with survey data generated through a program logic evaluation.
Aim
To explore nurses' perceptions of the implementation of clinical supervision, specifically addressing training adequacy, participation rates, organisational support, cultural growth and relational capacity development.
Design
A cross‐sectional survey of nursing supervisees was conducted within a program of research investigating the governmental implementation of clinical supervision.
Method
A survey of 366 participating nurses across four separate organisations addressed the following outcome evaluation questions, arising from program logic objectives: Are nurses currently engaged in clinical supervision? What is the relationship between clinical supervision implementation and: (1) nurses' preparation for clinical supervision, (2) their experience of the organisation valuing clinical supervision and (3) valuing nurses' own wellbeing and (4) nurses' perception of their own growth in relational practice?
Results
The findings affirm the clinical supervision implementation program by showing positive associations for the intended outcomes. Nurses reported: they had sufficient training in clinical supervision; their workplaces were experienced as supportive of clinical supervision and nurturing of the participants; and they had growth in relational ability. Each positive finding was significantly stronger for the sub‐sample (65%) of study participants who were currently engaged in clinical supervision compared to those who were not.
Conclusion
The study foregrounds the contribution of program logic, within a multifaceted initiative and including a strong authorising environment, to the implementation of clinical supervision.
Implications for the Profession and/or Patient Care
Implementation of clinical supervision across services can be enabled by values‐congruent strategies, including high‐level authorising, stakeholder objective setting, training and coalition of change agents.
Impact
This paper addresses the gap between numerous local intervention studies of clinical supervision for nurses and the lack of empirical studies informing system‐wide implementation approaches. Our survey investigating implementation outcomes shows that nurses experience of the implementation was aligned to program objectives: participating nurses considered themselves effectively trained for clinical supervision and supported by the organisation, with a positive impact on their own practice. This study can assist organisations in considering large‐scale implementation of clinical supervision, with a future focus on levels of uptake and impact on practice.
Reporting Method
We have adhered to relevant EQUATOR guidelines for survey method (i.e., the CROSS checklist).
Patient or Public Contribution
Mental Health Consumer and Carer Advisors within the Office of the Chief Mental Health Nurse, Department of Health and Human Services, Victoria, contributed to the establishment of the research evaluation objectives and related survey items. They contributed perspectives via initial project design meetings and further feedback informing the final version of the program logic.
Keywords: clinical supervision, framework, implementation science, mental health, mental health nursing, program logic
Summary.
- What does this paper contribute to the wider global clinical community?
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○The results suggest that a supportive organisational culture and training adequacy contribute to nurses' perceptions of effective implementation; indications of effectiveness were organisational valuing of clinical supervision and nurses' growth in relational work.
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○The method of co‐developing with stakeholders a program logic for implementation shows potential, both to keep focus on the purpose of implementation activity and to inform and generate outcome measures.
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○The study provides support for a CS implementation process framed by principles of CS itself: prioritising relationality, attending to nurses' development needs and mobilising participants' agency to achieve change.
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○
1. Introduction
Clinical supervision is regarded as a valuable part of the training and ongoing professional development of health and social care practitioners (Rothwell et al. 2021). As an international review of implementation barriers to clinical supervision shows, clinical supervision practices have been implemented in numerous forms in nursing, depending on local educational and organisational contexts and drivers (Masamha et al. 2022). Despite the wide acceptance of the uptake and benefits of clinical supervision in nursing, systematic reviews show empirical evidence of the benefits of supervision is not convincing because much research is limited in scope, poorly contextualised and low‐quality (Buus and Gonge 2009; Pollock et al. 2017). The dissonance between the belief in the impact and implementation of clinical supervision and the actual, available evidence provides impetus for robust evaluation of well contextualised implementation efforts (Masamha et al. 2022). Focusing on mental health nursing, a survey of all Trusts in England showed that evaluation was lacking and clinical supervision quality was undermined by managerial focus (White and Winstanley 2021). In this paper, we report survey findings from a governmental project using a co‐designed program logic to guide the evaluation of clinical supervision implementation for nurses across four Australian mental health services.
2. Background
A review of 87 studies identified many barriers to sustained implementation of effective clinical supervision in nursing, with the lack of time and resources invested being significant impediments to quality outcomes (Masamha et al. 2022). However, in supervision research and evaluation, a barrier is typically also described as an inverted facilitator, for instance, ‘no time for supervision’ (barrier) versus ‘time for supervision’ (facilitator), which could indicate a general but relatively un‐nuanced understanding of complex implementation contexts (Rothwell et al. 2021; Gonge and Buus 2016). The practice field in focus here is mental health nursing, where clinical supervision has long been identified as important for therapeutic practice and nurses' own wellbeing (Lynch and Happell 2008a).
Reports on the implementation of clinical supervision for mental health nurses have highlighted well‐primed organisational contexts as crucial to quality uptake and sustained results. White and Winstanley (2021) surveyed trusts regarding clinical supervision for mental health nurses across England, finding inadequate evaluation and Lynch and Happell (2008a, 2008c) explored implementation at a rural mental health service in Australia by reviewing documents and interviewing participants 2 years after the start of the implementation processes. Their analysis identified six stages in the implementation and drew initially on Driscoll's (2006) model for the implementation of supervision, most notably the identification of ‘pushing and resisting forces’ (Lynch and Happell 2008b, p. 73). However, after finding this approach too crude and static, Lynch and Happell (2008b) developed their own model, with five steps further emphasising cultural and organisational preparedness, planning and reviewing.
A pilot study by Taylor and Harrison (2010) showed that clinical supervision education was followed by a modest increase in uptake and suggested that links to other professional disciplines could aid sustainability. As part of a randomised clinical trial, White and Winstanley (2010) developed an educational intervention with six sessions for supervisors, where 24 mental health nurses from different Australian sites were trained to be group supervisors for local nurses over a 12‐month observation period. While supervisors had significantly higher total scores on the Manchester Clinical Supervision Scale (MCSS) after participating in the training, the supervisees' MCSS total scores did not change significantly. Complicating these findings, White and Winstanley noted that two‐thirds of the participating sites had experienced major changes to service provision (White and Winstanley 2010). Moreover, supplementary qualitative data (diaries and interviews) described the organisational culture as reluctant to change and an ambiguous role of management in establishing and maintaining clinical supervision (White and Winstanley 2009, 2010). In a similar vein, Buus et al. (2013) developed and implemented a manualised training course, based on action learning principles for mental health nursing supervisees. This study included a ‘meta‐supervision’ process, designed to strengthen supervision outcomes by articulating and actively addressing barriers to their supervision (Buus et al. 2013, 2016; Gonge and Buus 2015). While the trial identified significant increases in observed participation rates, it also revealed that the intervention worked best on individuals and wards already actively engaged in clinical supervision.
The studies above exemplify some of the complex relationships between individual staff members and the wider organisation, as well as between participation, benefits and the size and character of the clinical supervision implementation intervention. The current study differs from these studies by drawing on a co‐designed program logic that supported the implementation processes. In evaluation, a program logic is valuable as it outlines the logical sequence of events and the hierarchy of aims that are anticipated to lead to desired organisational change (Owen 2006). An expanded logic evaluation model may specify both outcome and process indicators, a resource to comprehensive evaluation. It usually shows diagrammatically the relationships between the program's objectives, activities, indicators and resources.
2.1. Implementing Clinical Supervision in Victoria, Australia
Commonly, implementation of clinical supervision in mental health nursing has been reliant on individual nurses' commitment or local advocates, rather than receiving widespread support from organisations or wider policy (Rothwell et al. 2021; Lynch and Happell 2008a). In contrast, in 2018, the Chief Mental Health Nurse in the state of Victoria, Australia, introduced a policy framework entitled Clinical supervision for mental health nurses: A framework for Victoria, to guide all mental health services to embed clinical supervision into nursing practices and service systems and processes (Department of Health and Human Services [DHHS] 2018). The framework was developed in collaboration with mental health nurse leaders and clinical supervision experts. Its primary purposes were to (1) show government support for nurses in their practice, professional development and growth, and to (2) guide organisations in developing, implementing and evaluating local clinical supervision policies and procedures tailored to their specific organisational requirements. Resourced by the Government of Victoria and stewarded by the Chief Mental Health Nurse, the policy framework created an authorising environment for the implementation of clinical supervision for nurses across Victoria's mental health services.
The government lead agency, the Office of the Chief Mental Health Nurse (CMHN), acted as facilitator rather than manager of the implementation, bringing together local implementers as partners and focusing on organisational enablers and cultures. An implementation team was formed, which comprised the Chief Mental Health Nurse (Chief MHN), and the Consumer and Carer Advisors to the office of Chief MHN, as well as leaders and clinical supervision experts from the mental health nursing field, representatives from many Victorian mental health services, and university‐based evaluators. This group met monthly for the duration of the five‐year project and was key to mobilising and communicating changes in practice. Over 5 years, the Chief MHN brought together key nurses across the organisations in a facilitated community of practice, a long‐term strategy that built relationships and support among like‐minded people.
Through workshops facilitated with key stakeholders in the first year of the project, in 2019, a program logic was developed in advance of commencing the implementation initiative (Hayes et al. 2011). Two study authors were invited to facilitate the program logic development, supporting the implementation team.
Figure 1 shows the resultant program logic: that is, a logical hierarchy of process and outcome objectives (encompassing objectives that mattered to clinical supervisees and supervisors, consumers, carers and managers) as a guide for evaluation of implementation of the 2018 policy initiative mentioned above. The approach established within the implementation drew on characteristics of supervision itself: time taken for sharing stories of local practice, the building of relationships with the implementation team, encouragement of learning and development among the implementors, and decentralised change activities with the aim of mobilising and entrusting local agents with responsibility for change.
FIGURE 1.
Program logic objectives for clinical supervision implementation in Victoria 2019.
Figure 1 includes a sequenced set of process and outcome objectives that the policy implementation team identified could indicate success through stages of CS implementation. The figure is read from the bottom to the top. Process objectives began with a project launch, followed by two columns of organisational change‐oriented objectives and training‐oriented objectives. These parallel columns culminated in a final process objective: ‘Local organisational, workforce & resourcing structures and training are in place across mental health organisations and settings to grow clinical supervision’. The implementation team's intended outcomes for nursing workforces and organisations are expressed in the figure as five outcome objectives. Outcome objective #4 relates directly to the implementation of clinical supervision: ‘70% of nurses are participating in supervision’. This indicates that stakeholders considered implementation would be a success if a majority of nurses were engaged in supervision. The set of outcome objectives in the figure makes explicit the organisational impacts that the government team intended. Two ultimate objectives were: positive impacts for consumer/carers experience of nurses' work (#7), and for nurses' own experience of themselves as ‘growing, especially in capacity for relational work’ (#8). The program logic was an essential foundation for the subsequent design of the present study. Note that 5 specific objectives addressed in this empirical study are bolded in the figure.
Beyond the program logic development stage, the tasks for the governmental implementation team were three‐fold: (1) to establish structures and strategies to support the implementation of clinical supervision across mental health services (DHHS 2018); (2) to empower and enable nurse leaders and clinical supervision champions, mobilising collective will, intentions and resources; and (3) to establish processes and gatherings that support creative, relational and reflexive ways of working, as transformational system change. Across the period of 2019–2023, three metropolitan services and two regional services committed to fully implementing the Framework across their mental health nursing settings, all with the support of the government implementation team, led by the Office of Chief Mental Health Nurse. (Victorian Government 2018; details may be accessed on the government website: https://www.safercare.vic.gov.au/best‐practice‐improvement/improvement‐projects/mental‐health‐improvement‐program/mental‐health‐nursing‐clinical‐supervision‐framework‐implementation).
In 2021, the current research team proposed to the government implementation team an evaluation study. We approached implementation leads at the five participating sites, and four out of five sites joined the program logic evaluation study. The participating sites consisted of three metropolitan and one regional public mental health service, constituting approximately 10% of mental health services for the state of Victoria, which has a total population of 6.6 million. All participating sites provided a range of services, including inpatient and community mental health services, with various specialities, for example, for children, youth and aged persons, as part of a larger public health service.
3. The Study
The study aim is to explore nurses' perceptions of the implementation of clinical supervision, specifically addressing training adequacy, participation rates, organisational support, cultural growth and relational capacity development. The aim focuses on five selected process and outcome objectives within the program logic. Survey data were gathered following a multi‐service implementation of clinical supervision, to uncover insights into these objectives. These five selected objectives, identified as key indicators of the program's progress, are bolded in Figure 1 to explicitly emphasise their centrality to this study.
3.1. Design‐ Program Logic Evaluation
The cross‐sectional survey study was a key element of an independent program logic evaluation of the state‐based project, undertaken from 2019 to 2023 to implement clinical supervision in services. Figure 1 presents a comprehensive set of process and outcome objectives set for policy implementation. This is a diagrammatic representation of the relationships between the objectives, activities and indicators of performance that made explicit both the intended organisational processes to implement clinical supervision across services and the ultimate aims (Dwyer and Makin 1997; Hayes et al. 2011).
The study takes an exploratory approach without a predetermined hypothesis, with the explicit goal of discovering implementation patterns, trends and insights regarding nurses' views on the achievement of the five selected programme objectives.
3.2. Study Setting and Sampling
The survey participants were recruited from the four public mental health services: one rural and three metropolitan. The population of eligible nurses was identified by participating organisations as N = 1478 nurses across the four services, and universal recruitment was undertaken. Nurses in these services include registered (RN) and enrolled (EN) nurses, all of whom were entitled to engage in supervision. Nurses' roles could be in inpatient, community or other settings such as consultation/liaison psychiatry, statewide services, non‐clinical educational or training roles.
3.3. Inclusion and Exclusion Criteria
The inclusion criterion for the survey was: employment as a registered or enrolled nurse and eligibility for clinical supervision in a participating public mental health service. This study presupposed that any nurse employed in participating sites was eligible to receive clinical supervision. Any ‘agency’ nursing staff—who may have been working a shift in participating sites but employed through an external company—was excluded.
4. Survey Instrument, Validity and Reliability
This study reports data related to five selected implementation objectives within the program logic model, as shown in Figure 1. These objectives were chosen for their importance in evaluating key aspects of the clinical supervision implementation. The selected objectives are:
Process Objective (A5): Supervision training needs are met.
Outcome Objective (4): More than 70% of nurses are participating in clinical supervision.
Outcome Objective (5): Clinical supervision practices in Victorian mental health services are valued by supervisees, supervisors and managers.
Outcome Objective (6): Supervisees, supervisors and managers experience the culture as healthy, reflective and growth oriented.
Outcome Objective (8): Nurses experience growth, especially in capacity for relational work.
The first is the process objective (Process Objective A5), which is that nurses have been ‘adequately trained’ in clinical supervision. The subsequent four outcome objectives are logically ordered, starting with the objective most proximal to implementation, i.e., the objective to achieve substantial uptake by nursers of Clinical Supervision (Outcome Objective 4), and progressing to the objective that is arguably the most distal: the objective of individual nurses ‘experiencing themselves as growing in their capacity to work relationally’ (Outcome Objective 8).
Survey questions were devised by the research team to explore nurses' perspectives on various aspects of the program objectives (as presented in Figure 2). Thus, survey items sought to uncover nurses' views on the implementation of clinical supervision, specifically their perception of the impact of the implementation of the policy framework on their preparation for clinical supervision, their organisation's valuing and support of clinical supervision, the health of its culture and their own growth in relational practice. Evaluation of other objectives within the logic model will be reported elsewhere.
FIGURE 2.
Survey design: Questions mapped to program logic objectives.
Using program logic to create survey questions in evaluation offers several advantages (NSW Ministry of Health 2023). For example, it helps formulate specific, relevant questions that relate directly to each component of the implementation process, thereby making the evaluation more targeted and effective. In this study, by designing questionnaires directly from the program logic created by stakeholders, we aimed to evaluate the aspects of implementation that were explicit statements of diverse stakeholder's needs or intentions for the program. Such program‐logic‐derived questions can support accountability, by directly linking to the implementation's stated goals and activities, generating evidence about the use of resources and the intended impact.
The reliability of the survey, which included one binary question and four Likert Scale questions, was confirmed through a high Cronbach's alpha coefficient (α = 0.78), indicating strong internal consistency among the four scaled questions.
5. Data Collection
5.1. Sites and Recruitment
All eligible nurses within the four participating mental health services were invited to participate via direct email sent through the healthcare services' nursing education teams; nurses were reminded via posters placed in nurses' stations and offices.
Data collection occurred between January and August 2023 through an anonymous online survey administered via the Research Electronic Data Capture (REDCap) software. This inclusive approach to recruitment and data collection was aimed at generating a representative sample.
6. Data Analysis
Data were imported into SPSS (IBM Corp, IBM SPSS Statistics for Windows, version 28.0, Armonk, New York: IBM Corp) for statistical analysis. In this study, descriptive statistics were used to provide an overview of participant demographics, including gender, nursing seniority/scope of practice (in line with the Australian tiered registration system for nurses based on scope of practice as per Nursing and Midwifery Board of Australia 2023), nurse's main role, work setting and age. Data were not normally distributed (p < 0.001, Kolmogorov–Smirnov and Shapiro–Wilk tests), and hence non‐parametric methods were employed. Chi‐square tests were used to assess categorical variables and explore associations between clinical supervision and demographic factors, including gender, nursing registration division, main role and work setting. Mann–Whitney U test was used to examine age differences in receiving clinical supervision. Chi‐square analyses examined clinical supervision experiences across demographic variables, to explore the experience of clinical supervision implementation among mental health nurses. Chi‐square analysis was also used to examine associations between receiving clinical supervision and participants' perceptions of clinical supervision and organisational variables. Additionally, correlation coefficients, calculated using Spearman's rho, explored relationships between key variables, including perceptions of clinical supervision, organisational support, growth in relational work and training adequacy. In this study, missing values were encountered due to non‐response by some participants, resulting in incomplete data for specific questions (Table 2). To address this issue, we conducted a complete case analysis, where only participants who responded to all relevant questions were included in the final analysis. A significance level of p < 0.05 was employed to indicate statistical significance for all tests conducted in this study.
TABLE 2.
Comparison of demographic characteristics between respondents and non‐respondents (n = 366).
| Currently receiving clinical supervision | ||||
|---|---|---|---|---|
| Responded | Non‐respondents | |||
| n | % | n | % | |
| Gender | ||||
| Male | 75 | 23 | 16 | 37 |
| Female | 243 | 75 | 27 | 63 |
| Other | 5 | 2 | 0 | 0 |
| (χ 2 (2) = 4.449, p = 0.108) | ||||
| Nursing registration division | ||||
| Registered nurse (Division 1) | 288 | 89 | 24 | 56 |
| Enrolled nurse (Division 2) | 35 | 11 | 19 | 44 |
| (χ 2 (1) = 33.558, p = < 0.001) | ||||
| Main role | ||||
| Clinical | 235 | 73 | 41 | 95 |
| Management | 20 | 6 | 0 | 0 |
| Education | 59 | 18 | 1 | 2 |
| Other | 9 | 3 | 1 | 2 |
| (χ 2 (3) = 11.143, p = 0.011) | ||||
| Setting | ||||
| Inpatient | 139 | 43 | 29 | 67 |
| Community | 120 | 37 | 10 | 23 |
| Inpatient and community | 45 | 14 | 3 | 7 |
| Other | 19 | 6 | 1 | 2 |
| (χ 2 (3) = 9.266, p = 0.026) | ||||
| Age (Mann–Whitney U test): U = 4049.500, Z = −1.283, p = 0.199 | ||||
Note: Respondents: Individuals who provided complete data. Non‐Respondents: Individuals who only responded to demographic questions but did not provide a response regarding receiving clinical supervision.
7. Ethical Considerations
The study protocol for this evaluation was approved by the Alfred Health ethics committee under the National Mutual Acceptance (ID: 79097) on 27 May 2022, and site‐specific approval was obtained at each participating site. The study was registered with the University of Melbourne Human Research Ethics Committee (ID: 2022‐24598‐29006‐1) on 30 May 2022.
A plain language statement was distributed within the research invitation. Informed consent was obtained on the first page of the online survey. The survey did not start if a participant did not give consent. All research‐related files were stored electronically and password‐protected, accessible only to the research team.
8. Results
The study obtained 422 responses out of the invited 1478 nurses, resulting in a response rate of 28.5%. Of the 422 responses, 366 participants completed the four Likert Scale questions regarding the impact of the clinical supervision implementation program, and 323 provided responses to the question concerning their current clinical supervision practices. The characteristics of the sample of 366 are presented in Table 1.
TABLE 1.
Characteristics of the sample (n = 366).
| n | % | |
|---|---|---|
| Supervisee characteristics | ||
| Gender | ||
| Male | 91 | 25 |
| Female | 270 | 74 |
| Other | 5 | 1 |
| Total | 366 | 100 |
| Nursing registration division | ||
| registered nurse (Division 1) | 312 | 85 |
| enrolled nurse (Division 2) | 54 | 15 |
| Total | 366 | 100 |
| Main role | ||
| Clinical | 276 | 75 |
| Management | 20 | 5 |
| Education | 60 | 16 |
| Consultant | 3 | 1 |
| Other | 7 | 2 |
| Total | 366 | 100 |
| Setting | ||
| Inpatient | 168 | 46 |
| Community | 130 | 36 |
| Both inpatient and community | 48 | 13 |
| Other | 20 | 5 |
| Total | 366 | 100 |
| Health service | ||
| Health service 1 | 142 | 39 |
| Health service 2 | 86 | 23 |
| Health service 3 | 75 | 20 |
| Health service 4 | 63 | 17 |
| Total | 366 | 100 |
The largest subgroup of participants (39%) was from metropolitan Service 1, as indicated in Table 1, and was mostly women (74%) working as Registered Nurses (RN, 85%) in clinical roles (75%). Respondents worked in various settings, with the largest portion in inpatient settings (46%), followed by community settings (36%), both inpatient and community settings (13%) and a smaller percentage in other settings (5%). The age range of respondents varied from 21 to 69, with a median age of 37 and quartiles at 29 and 49. Out of the 366 participants, most respondents (88%) had experienced clinical supervision at least once. Among those who responded (n = 323), 65% were currently receiving clinical supervision, while 35% were not.
Table 2 shows that the nurses who did not report whether or not they were currently engaged in clinical supervision (n = 44) differed from those who did report, in that their role was clinical, and they were more likely to be enrolled nurses working in inpatient settings. These demographic features aligned with those who did respond to the question and who were not currently receiving supervision in the total sample.
The Chi‐square analysis examined the association between receiving clinical supervision and demographic variables, including gender, nursing registration division, main role and setting; these results are presented in Table 3. There was no association between gender and clinical supervision or between main roles and clinical supervision. A statistically significant association was observed between nursing registration and clinical supervision (p = 0.031). A statistically significant association was also identified between work settings and clinical supervision (p = 0.004). These results indicated that in terms of receiving clinical supervision, gender and main role do not appear to be determining factors. However, the nursing registration division and setting appear to be significant factors that influence clinical supervision. Approximately 67% of Registered Nurses (Division 1) and 49% of Enrolled Nurses (Division 2) received clinical supervision. Of nurses working only in community settings, 67% were engaged in supervision and 55% of nurses in inpatient settings.
TABLE 3.
Distribution of clinical supervision across demographic variables (n = 323).
| Are you currently receiving clinical supervision? | ||||
|---|---|---|---|---|
| Yes | No | |||
| n | % | n | % | |
| Gender | ||||
| Male | 48 | 23 | 27 | 24 |
| Female | 159 | 76 | 84 | 74 |
| Other | 3 | 1 | 2 | 2 |
| (χ 2 (2) = 0.108, p = 0.948) | ||||
| Nursing registration division | ||||
| Registered nurse (Division 1) | 193 | 92 | 95 | 84 |
| Enrolled nurse (Division 2) | 17 | 8 | 18 | 16 |
| (χ 2 (1) = 4.667, p = 0.031) | ||||
| Main role | ||||
| Clinical | 144 | 69 | 91 | 81 |
| Management | 15 | 7 | 5 | 4 |
| Education | 45 | 21 | 14 | 12 |
| Other | 6 | 3 | 3 | 3 |
| (χ 2 (3) = 5.618, p = 0.132) | ||||
| Setting | ||||
| Inpatient | 77 | 37 | 62 | 55 |
| Community | 81 | 39 | 39 | 35 |
| Inpatient and community | 36 | 17 | 9 | 8 |
| Other | 16 | 8 | 3 | 3 |
| (χ 2 (3) = 13.501, p = 0.004) | ||||
The Mann–Whitney U test examined the age distribution between participants currently receiving clinical supervision and those who did not. There was no significant difference in age between nurses with current clinical supervision experience (n = 181) and those without (n = 86).
Results from the four program outcome questions, relating to perceptions of clinical supervision and organisational support, are presented in Table 4. Most respondents (71%) felt they had received adequate training for clinical supervision. Participants considered that their organisations prioritised clinical supervision, with 39% agreeing and 23% strongly agreeing. Furthermore, 47% agreed and 22% strongly agreed that the organisational culture supported their wellbeing and growth. A high proportion of respondents (82%) perceived growth in their own capacity for relational work as nurses. Analysis of the survey data enabled us to assess the outcomes of clinical supervision implementation on five key indicators within the program logic. Further analysis shows associations between these outcomes.
TABLE 4.
Perceptions of clinical supervision & organisational support (n = 366).
| n | % | ||
|---|---|---|---|
| I have had the training I need to effectively use clinical supervision. | Strongly disagree | 14 | 4 |
| Disagree | 39 | 11 | |
| No opinion | 54 | 15 | |
| Agree | 189 | 52 | |
| Strongly agree | 70 | 19 | |
| Total | 366 | 100 | |
| The organisation gives high priority to my clinical supervision. | Strongly disagree | 19 | 5 |
| Disagree | 60 | 16 | |
| No opinion | 60 | 16 | |
| Agree | 141 | 39 | |
| Strongly agree | 86 | 23 | |
| Total | 366 | 100 | |
| The organisational culture supports my well‐being and growth. | Strongly disagree | 12 | 3 |
| Disagree | 32 | 9 | |
| No opinion | 67 | 18 | |
| Agree | 173 | 47 | |
| Strongly agree | 82 | 22 | |
| Total | 366 | 100 | |
| I am growing in my capacity for relational work as a nurse. | Strongly disagree | 3 | 1 |
| Disagree | 9 | 2 | |
| No opinion | 57 | 16 | |
| Agree | 200 | 55 | |
| Strongly agree | 97 | 27 | |
| Total | 366 | 100 |
Table 5 displays the significant associations found through Chi‐square analysis between receiving clinical supervision and organisational factors (priority and culture), growth in relational work, and training adequacy among mental health nurses. Results showed a significant association between receiving clinical supervision and the perceived priority given to clinical supervision by the organisation (χ 2 = 26.810, df = 4, p < 0.001). This suggests that nurses who receive clinical supervision are more likely to perceive that their organisation prioritises this aspect of their work.
TABLE 5.
Associations between current clinical supervision and participants' perceptions of self and organisation (n = 323).
| Currently receiving clinical supervision | ||||
|---|---|---|---|---|
| Yes | No | |||
| n | % | n | % | |
| Training adequacy | ||||
| Strongly disagree | 6 | 3 | 5 | 4 |
| Disagree | 9 | 4 | 18 | 16 |
| No opinion | 27 | 13 | 18 | 16 |
| Agree | 115 | 55 | 60 | 53 |
| Strongly agree | 53 | 25 | 12 | 11 |
| (χ 2 (4) = 20.782, p < 0.001) | ||||
| High priority for clinical supervision | ||||
| Strongly disagree | 8 | 4 | 5 | 4 |
| Disagree | 24 | 11 | 29 | 26 |
| No opinion | 22 | 11 | 22 | 20 |
| Agree | 87 | 41 | 44 | 39 |
| Strongly agree | 69 | 33 | 13 | 12 |
| (χ 2 (4) = 26.810, p < 0.001) | ||||
| Organisational culture supports wellbeing | ||||
| Strongly disagree | 4 | 2 | 5 | 4 |
| Disagree | 14 | 7 | 15 | 13 |
| No opinion | 36 | 17 | 25 | 22 |
| Agree | 91 | 43 | 56 | 50 |
| Strongly agree | 65 | 31 | 12 | 11 |
| (χ 2 (4) = 19.579, p < 0.001) | ||||
| Growth in relational work | ||||
| Strongly disagree | 1 | 1 | 1 | 1 |
| Disagree | 2 | 1 | 7 | 6 |
| No opinion | 25 | 12 | 26 | 23 |
| Agree | 104 | 50 | 69 | 61 |
| Strongly agree | 78 | 37 | 10 | 9 |
| (χ 2 (4) = 36.594, p < 0.001) | ||||
The findings in Table 5 indicate a significant association between clinical supervision and the organisational culture supporting wellbeing and growth (χ 2 = 19.579, df = 4, p < 0.001). This implies that clinical supervision may be linked to a more positive perception of the organisational culture regarding personal growth and wellbeing. A significant association was found between clinical supervision and nurses' perceived growth in relational work (χ 2 = 36.594, df = 4, p < 0.001). This suggests that clinical supervision is associated with an increased perception of growth in relational skills among nurses. A significant association was also identified between clinical supervision and perceived training adequacy (χ 2 = 20.782, df = 4, p < 0.001). This suggests that nurses who receive clinical supervision are more likely to perceive that they received adequate training.
The study investigated nurses' views of the associations between the four implementation objectives: perceived adequacy of training, high priority given to clinical supervision, perceptions of organisational culture, growth in relational work. The results presented in Table 6 show the relationships between these variables based on Spearman's rank correlation coefficients.
TABLE 6.
Correlation coefficients among key variables (n = 366).
| Training adequacy | High priority in clinical supervision | Organisational culture support | Growth in relational work | |
|---|---|---|---|---|
| Training adequacy | — | |||
| High priority for clinical supervision | 0.505** | — | ||
| Org culture supports wellbeing | 0.317** | 0.660** | — | |
| Growth in relational work | 0.446** | 0.517** | 0.638** | — |
Correlation is significant at the 0.001 level (2‐tailed).
Nurses were more likely to perceive high priority in clinical supervision when the organisational culture supported their wellbeing and growth (rho = 0.660, p < 0.001), when they felt they were growing in their capacity for relational work (rho = 0.517, p < 0.001), and when they perceived they had adequate training (rho = 0.505, p < 0.001). Nurses were more likely to feel that the organisational culture supported their wellbeing and growth when they also felt they were growing in their capacity for relational work (rho = 0.638, p < 0.001) and when they perceived they had adequate training (rho = 0.317, p < 0.001). Nurses were more likely to feel they were growing in their capacity for relational work when they perceived they had adequate training (rho = 0.446, p < 0.001).
The study investigated the associations between high priority given to clinical supervision, perceptions of organisational culture, growth in relational work and adequacy of training. The results presented in Tables 7A and 7B show the relationships between these variables based on Spearman's rank correlation coefficients for two groups of nurses: those nurses who were currently receiving and not receiving clinical supervision.
TABLE 7A.
Correlation coefficients among key variables for nurses receiving clinical supervision (n = 210).
| Training adequacy | High priority in clinical supervision | Organisational culture support | Growth in relational work | |
|---|---|---|---|---|
| Training adequacy | — | |||
| High priority for clinical supervision | 0.465** | — | ||
| Org culture supports wellbeing | 0.344** | 0.705** | — | |
| Growth in relational work | 0.456** | 0.576** | 0.645** | — |
Correlation is significant at the 0.001 level (2‐tailed).
TABLE 7B.
Correlation coefficients among key variables for nurses not receiving clinical supervision (n = 113).
| Training adequacy | High priority in clinical supervision | Organisational culture support | Growth in relational work | |
|---|---|---|---|---|
| Training adequacy | — | |||
| High priority for clinical supervision | 0.488** | — | ||
| Org culture supports wellbeing | 0.212* | 0.581** | — | |
| Growth in relational work | 0.328** | 0.373** | 0.601** | — |
Correlation is significant at the 0.05 level (2‐tailed).
Correlation is significant at the 0.001 level (2‐tailed).
Results from Table 7A showed that nurses currently receiving clinical supervision were more likely to perceive high priority in clinical supervision when the organisational culture supported their wellbeing and growth (rho = 0.705, p < 0.001), when they felt they were growing in their capacity for relational work (rho = 0.576, p < 0.001), and when they perceived they had adequate training (rho = 0.465, p < 0.001). Nurses currently receiving clinical supervision were more likely to feel that the organisational culture supported their wellbeing and growth when they also felt they were growing in their capacity for relational work (rho = 0.645, p < 0.001) and when they perceived they had adequate training (rho = 0.344, p < 0.001). Nurses currently receiving clinical supervision were more likely to feel they were growing in their capacity for relational work when they perceived they had adequate training (rho = 0.456, p < 0.001).
Results from Table 7B showed that even for those not currently receiving clinical supervision, there was a positive association between the perception of high priority afforded to clinical supervision, when the organisational culture supported their wellbeing and growth (rho = 0. 581, p < 0.001), when they felt they were growing in their capacity for relational work (rho = 0. 373, p < 0.001), and when they perceived they had adequate training (rho = 0. 488, p < 0.001). Nurses not currently receiving clinical supervision were more likely to feel that the organisational culture supported their wellbeing and growth when they also felt they were growing in their capacity for relational work (rho = 0. 601, p < 0.001). The association with training adequacy was weaker (rho = 0. 212, p = 0.024). Nurses not currently receiving clinical supervision were more likely to feel they were growing in their capacity for relational work when they perceived they had adequate training (rho = 0. 328, p < 0.001, Table 7B).
9. Discussion
We conducted this study as part of a research program investigating the governmental implementation of a clinical supervision policy framework for MHNs across multiple mental health services in Victoria, Australia. Our study focused on the views of nurses regarding implementation, as they were the central stakeholders in the implementation of the policy. The findings overall are that nurses considered implementation achieved the five objectives. Analysis also showed relationships between objectives: from effective training, to clinical supervision uptake, to organisational support for clinical supervision, a positive culture and nurses' experience of growing.
The discussion brings forward: (1) the novel use of program logic for the evaluation, (2) the alignment between clinical supervision's established relational values, program implementation objectives, processes and reported outcomes, and (3) the importance of explicitly addressing the wider context, in efforts to implement clinical supervision in nursing workforces.
9.1. Foregrounding Program Logic
Our approach to using program logic as an organising frame for CS implementation evaluation is novel. Although program logic has been used to evaluate the implementation of other interventions in public sector settings (Owen 2006; Hayes et al. 2011), to our knowledge, this is the first time it has been used to evaluate the implementation of clinical supervision. Typically, the objectives of CS implementation studies are determined by researchers, supervisors and managers. One such example (Smith et al. 2022) reports a researcher‐led audit of a local implementation using evidence‐based criteria and the advice of an academic and team leaders, with no inclusion of supervisee or service user perspectives.
Using a program logic approach allowed us to create a specific and relevant data collection tool, purposely shaped by the priorities of the stakeholders. We generated evaluation questions that mattered to diverse stakeholders, including service users and families. While program logic often establishes objectives, our direct evaluation of nurses' experiences against that key set of objectives arising from the perspective of stakeholders is an additional contribution.
9.2. Findings That Illustrate the Logic
Overall, most participants felt they had received adequate training for clinical supervision, that their organisations prioritised clinical supervision and that the organisational culture supported their wellbeing and growth. Previous implementation studies (Lynch and Happell 2008a, 2008b, 2008c, White and Winstanley 2009) and reviews (Ryu et al. 2024) highlight the failure of CS uptake associated with inadequate training for supervisors and supervisees. Moreover, many participants here perceived a growth in their capacity for relational work, also an important outcome (McCarthy et al. 2021).
Concerning engagement in clinical supervision, the research population included nurses who were and were not engaged in CS. A large majority of participants in this study had received clinical supervision at least once, and a majority were currently receiving clinical supervision. When reported in studies, the actual rate of uptake across a population of nurses is low (Kenny and Allenby 2013). Considering the extent of clinical supervision literature, it is notable that the rate of uptake of clinical supervision across a studied workforce is rarely reported. Studies that research aspects of supervision do not include this population uptake data, which is fundamental for reliable analyses of supervision outcomes (Gonge and Buus 2011). Further, participants engaged in clinical supervision here reported significantly more positive ratings of training preparation, organisational culture and growth in their own relational practice. The results suggest that a supportive organisational culture, training adequacy and supervision engagement itself contribute to nurses' perceptions of effectiveness, in terms of the importance of clinical supervision and their own growth in relational work. This cumulative impact of organisational elements reflects previous case studies that suggest implementation requires a multifaceted intervention and organisational commitment (Lynch and Happell 2008a, 2008b, 2008c).
According to literature reviews, previous evaluations have commonly reported supervisee satisfaction with supervision (Cutcliffe et al. 2018; Pollock et al. 2017), but not outcomes that were explicitly shown to be important for other stakeholders, including funders, managers, nurses and service users. The survey findings here are distinctive for their tight association with key objectives of multiple stakeholders committed to supporting the implementation of clinical supervision, as expressed in the program logic.
Without the program logic to guide evaluation, previous implementation research has overlooked such considerations as supervisee experience of culture and personal growth. Our evaluation objectives and the findings draw attention to an association between nurses' sense of their organisation valuing nurses' wellbeing and the nurses' uptake of supervision. This project redresses a common barrier to supervision identified in reviews by Masamha et al. (2022) and Ryu et al. (2024). That is, the lack of organisational interest is a barrier to effective implementation of supervision.
We propose that program logic mapping is worth consideration in other large and complex organisational change initiatives, for guarding against project scope creep during extensive implementation. It may be that the foundation work on the program logic focused the thinking of local implementers on more than ‘merely’ ensuring training, increasing the numbers of nurses in supervision, satisfaction with supervision, or organisational priorities, such as workforce retention (Hyrkäs et al. 2006). Equally, the use of a logic at the outset may have focused stakeholders in this project on goals beyond operational considerations and common barriers, such as cost and shiftwork, that dominate the current literature (Rothwell et al. 2021). The following section discusses further the relational intentions embedded in the implementation project.
9.3. Aligning Implementation Process With CS Values and Intentions
Clinical supervision is commonly viewed as a relational, growth‐oriented process whereby purposeful engagement in the clinical supervisory relationship is a key enabler of effective clinical supervision (Bond and Holland 2011; DHHS 2018; Rothwell et al. 2021; Sharrock et al. 2019). There can be a dissonance between the purpose of CS and the process of its implementation. For example, in an implementation project in Wales, Smith et al. (2022) describe the purpose of CS as a process ‘where staff can uncover their own personal emotions, reflect on practice and receive feedback’ (p. 524). Yet the implementation process is described in this instrumental way: 'The aim of this project is to improve compliance with evidence‐based criteria' (p. 525). While studies recognise the centrality of relationship in supervision, (such as Saab et al. (2021) in Wales, White and Winstanley (2009) in Australia) reflexivity and relational learning is frequently not a noted feature of the implementation process itself. Alternatively, the dissonance can be framed in terms of the Clinical Supervision functions as per Proctor (2008), whereby the normative purpose of CS implementation can overshadow formative and restorative purposes. Foundational work on the project logic aided an implementation process that prioritised relationality, and eschewed implementation that could have been transactional, such as one emphasising ‘compliance’, organisational outputs or cost efficiency.
Notably, nurses' relational skills were explicitly given highest priority in the implementation objectives within the program logic ‘(Outcome Objective 8: Nurses experience that they are growing, especially in capacity for relational work)’. The project process paralleled fundamentals of clinical supervision, such as relationship, reflection and choice (DHHS 2018; Driscoll 2006). This alignment began with the program logic workshop process that was intentionally inclusive of people with diverse perspectives, including consumers and carer advisors. Moreover, the clinical supervision policy implementation was purposefully embedded within a five‐year supportive, reflexive and relational change process. Rather than acting to manage project teams, the lead agency (Office of the Chief Mental Health Nurse) brought together key nurses across the organisations in a facilitated community of practice, a long‐term strategy that built relationships across the sector. The consistent, relational intention across this policy implementation is reflected in the findings of the study. We postulate that implementation of clinical supervision across services can be enabled by these values‐congruent strategies, including high level authorising, stakeholder objective setting, training and coalition of change agents.
9.4. Findings That Illustrate the Relational Intentions
Our examination of the associations between nurses' perceived adequacy of training, their organisation's prioritisation of clinical supervision and the health of its culture, and their own growth in capacity for relational work highlighted the interconnection between these factors. Across all four organisations, nurses were more likely to feel that the organisational culture supported their wellbeing and growth when they also felt they were growing in their capacity for relational work and were more likely to feel they were growing in their capacity for relational work when they perceived they had adequate training. Training has been a prominent feature of other studies of clinical supervision (Lynch and Happell 2008a, 2008b; Lakeman and Glasgow 2009), but the increase in clinical supervision uptake as an outcome has not been strong, reinforcing the observation that training in itself is insufficient to impact culture.
These associations show nurses experienced growth in their capacity for relational work (highest level objective), and we postulate that adequate training and the organisations' valuing of clinical supervision and the health of its culture (three intermediate objectives) were likely moderators of this outcome. The review by Ryu et al. (2024) shows that a lack of managerial commitment to nurses' supervision needs and a lack of wider organisational support are common obstacles to supervision engagement and quality. This study shows nurses as individuals who perceived organisational support for their growth and wellbeing, and were correspondingly hopeful themselves about growth in relational capability. Even though nurses' ratings against all the objectives were generally high across the four organisations, and associations between the objectives were also significant for those not receiving supervision, current receipt of supervision was associated with a heightened experience across the five objectives. So, taken together, the findings align with the overall positive relational emphasis of supervision that underpinned the implementation objectives and process (Sharrock et al. 2019). We tentatively suggest that a high level of clinical supervision uptake is good for organisations, and good for nurses' growth.
9.5. Implementation With Focus on Context
Reports on the implementation of clinical supervision for mental health nurses have emphasised the importance of organisational context for achieving and sustaining success (e.g., Lynch and Happell 2008a, 2008b, 2008c). This study advances current implementation evidence by bringing attention empirically to the local and wider context for implementation of clinical supervision. In regard to practice across the four organisations, the issue of participants' seniority and scope of practice, reflected in nursing registration division and practice setting, were influential factors in the extent of engagement in clinical supervision by nurses. That is, approximately two‐thirds of Registered Nurses were receiving clinical supervision, while about half of Enrolled Nurses were receiving clinical supervision. Concerning practice settings, a higher proportion of nurses who work in community settings received clinical supervision compared to those working in inpatient settings. Notably, Enrolled Nurses are commonly employed in inpatient settings. The difference in clinical supervision uptake can potentially be explained by the well recognised logistical challenges that inpatient nurses face, such as shift work and rostering (Buus et al. 2016; McCarthy et al. 2021; Saab et al. 2021). Nevertheless, achieving a majority engagement of nurses in clinical supervision across these organisations represents achievement of the outcome objective (#7) to normalise participation in clinical supervision for nurses in these services, which is an advance on previous observational (Teasdale et al. 2001) and intervention studies (Taylor and Harrison 2010; Buus et al. 2016).
Nurses perceived high prioritisation of clinical supervision by their own organisation, a culture supporting their wellbeing and growth, and adequate clinical supervision training. These associated characteristics re‐emphasise the importance of priming any organisational context for broad scale implementation of practice change, such as clinical supervision (Weiner 2009). Results reinforce previous findings that nurses receiving clinical supervision view their organisation as supportive (Teasdale et al. 2001). The findings invite the question: how different might the experiences of nurses be in other organisations that had not opted in to this significant practice change process? There may well be organisations that are poorly positioned to attempt clinical supervision implementation; there may also be fewer positive experiences among the many nurses within the participating organisations who chose not to participate in the study. Thus, even a multifaceted implementation approach such as this is not a panacea (Gonge and Buus 2015); we cannot assume that this precise set of strategies will work for less primed organisations. All clinical supervision implementation initiatives will require attention to organisational contexts; therefore highly prescriptive (one size fits all) approaches are unlikely to achieve successful clinical supervision implementation (Rothwell et al. 2021).
Looking to the wider context, the implementation activity would not have taken the shape it did without the policy framework, the authorising of mental health leaders in government and the development of a program logic that articulated outcomes before implementation commencement. According to the recent scoping review of factors that influence clinical supervision implementation by Ryu et al. (2024), policy and external pressure are underexplored topics within the clinical supervision implementation. Therefore, our study addresses this gap by identifying the policy framework and ways government can enable local clinical supervision implementation by establishing a clear authorising environment (Weiner 2009). Given that the authors here are not the implementers, detailing how the implementation was carried out at each organisation is beyond our scope; instead, we emphasise the shared authorising environment that is the government contribution. Despite differences and challenges across service contexts, this study showed that a high‐level authorising and programmed approach facilitated change.
10. Conclusion
This study highlights the broad impacts achieved through a policy launch, the development and application of program logic by key stakeholders, and organisations' initiatives adopted and supported through an opt‐in approach. An external authorising environment can foster autonomy and creativity in organisations to deliver what works for them. This approach, which is both non‐prescriptive and empowering, mirrors the core principles of clinical supervision, with a strong emphasis on choice and self‐accountability.
Significant differences in engagement in clinical supervision based on nursing registration category and work setting highlight existing barriers. Understanding these differences could contribute to breaking down barriers and improving overall engagement in clinical supervision.
The positive associations between organisational variables (priority, culture), growth in relational work, and training adequacy among nurses receiving clinical supervision reported in this study highlight the key role of active organisational support (Teasdale et al. 2001; Weiner 2009). Organisations aiming to implement clinical supervision are guided by this study to attend equally to building a culture that values clinical supervision. This involves creating a supportive environment within the organisation and implementing practices that prioritise the growth and wellbeing of nurses.
11. Strength and Limitations of the Work
While all eligible nurses were invited and a relatively large sample was recruited, the response was only 28.5%, and we acknowledge this as a limitation in terms of potential selection bias and reduced generalisability. The follow‐up strategies of public posters may have introduced a convenience element to sampling. Furthermore, the survey items were based on a programme logic designed to guide and support implementation processes, not a theoretically informed selection of items, as, for instance, was done in the development of the Manchester Clinical Supervision Scale, which was based on Kadushin's/Proctor's model (White and Winstanley 2010). Further, only a single item was used at each data collection point; multiple items (scales) at each data point may be a more robust approach. Finally, all correlations between items were very high, which could indicate that we were measuring the same latent construct (the selection bias mentioned above is part of this issue).
12. Recommendations for Further Research
For this field of research to progress, organisations must commit to collecting routine data on clinical supervision participation and other clinical supervision relevant outcomes, for complete datasets and robust analyses. There is an invitation here also to regularly explore mental health nurses' experience of growing in relational practice, beyond the reported cross‐sectional perception.
Intervention and implementation studies must build on a multifaceted approach, encompassing authorising and policy settings, multilevel organisational teams and training. Outcomes to examine are: priority given to clinical supervision, nurses' wellbeing, orientation to relational work, training adequacy, nurses' experience of clinical supervision.
Specific intervention and implementation studies are required to understand the best approaches to achieve high uptake of quality supervision for mental health nurses in inpatient settings. Beyond this outcome for nurses, the outstanding objectives in the program logic drive research towards the investigation of outcomes of clinical supervision for consumers and families, the quality of engagement with nurses and the overall experience of care.
13. Implications for Policy and Practice
Ensuring mental health nurses receive adequate training can enhance their readiness for clinical supervision. However, clinical supervision implementation requires more than training as an intervention. Organisations should therefore adopt an approach that recognises the interconnectedness of these factors, commit to initiatives that focus on making clinical supervision a priority, building a supportive culture, enhancing relational skills and ensuring adequate training.
Clinical supervision implementation is commonly initiated at the healthcare provider organisation level. This implication from this study is that future implementation of clinical supervision would benefit from the authorising value of higher‐level policy initiatives for whole jurisdictions.
Author Contributions
B.H., H.R., N.B., T.K. and R.P. made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; All the authors were involved in drafting the manuscript or revising it critically for important intellectual content and also have given final approval of the version to be published. Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content. All the authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Conflicts of Interest
The authors declare no conflicts of interest.
Peer Review
The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.17101.
Acknowledgements
We would like to acknowledge funding support from the Office of the Chief Mental Health Nurse and Safer Care Victoria, which made the ethics and analysis work for this evaluation possible. We would like to acknowledge Ms. Anna Love, the Chief Mental Health Nurse, and Ms. Kate Thwaites, the Deputy Chief Mental Health Nurse, for their wider collaborative invitation to us to contribute to the policy implementation project. Furthermore, we would like to acknowledge Ms. Julie Anderson and Ms. Michelle Swann, who participated as lived experience advisors in the program logic workshop, upon which the survey was based. Finally, we would like to acknowledge the site principal investigators who led data collection at each site, including Mr. Adam Daly, Mr. Francis McCormick, Ms. Jessica Naqqash, and Mr. Stuart Wall. Open access publishing facilitated by The University of Melbourne, as part of the Wiley ‐ The University of Melbourne agreement via the Council of Australian University Librarians.
Funding: This work was supported by State Government of Victoria, Safercare.
C. There is a statistician on the author team: Ms Roshani Prematunga.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.