“I see your punitive measure and I raise you a person-centered bar”: Supervisory Strategies to Promote Adoption of Person-Centered Care

Abstract

Person-centered care remains a high priority within community mental health services. Clinical supervision is an embedded resource for professional development and promotion of high quality care. This study examined supervisory strategies during the implementation of person-centered care planning (PCCP) across two northeastern US States. A criterion sample of supervisor-provider teams participated in qualitative interviews (N = 34) and direct observation from 2016–2017. Modified grounded theory analyses were conducted and three supervisory strategies were identified. Supervisory attunement to providers (knowing their audience), active collaborative engagement with providers (practicing together), and infusing reminders and opportunities for feedback (chipping away) were critical strategies to engage providers in adopting PCCP. These strategies changed providers’ practice patterns by improving supervisors’ calibration to dynamic contextual and individual needs during implementation and communicating supervisors’ expectations of PCCP enactment. Workplace-based clinical supervision holds promise as a key intervention point to embed high quality care.

Introduction

Person-centered healthcare is widely acknowledged in the United States as both an ethical (Anthony, 1990; Atterbury, 2014) and policy mandate (Department of Health and Human Services, 2003; Institute of Medicine, 2006) with a promising (Stanhope, Ingoglia, Schmelter, & Marcus, 2013) and growing (Stanhope et al., 2015) evidence-base. Person-centered healthcare, aptly named, endeavors just that – centering people (rather than disease) in the assessment, planning, and delivery process of treatment. Perhaps not surprisingly given this context, healthcare providers consistently agree that they are committed to, and often report already providing, person-centered care (O’Connell, Tondora, Croog, Evans, & Davidson, 2005). Yet, patients continue to report otherwise. Reported patient experiences are consistent with traditional asymmetries in acknowledged expertise and clinical decision-making power within their interactions with providers, which has led to pervasive disengagement from services (Institute of Medicine, 2015). In addition, a review of treatment plans has similarly found low levels of fidelity to person-centered care (Choy-Brown et al. 2020). In this way, person-centered care (PCC) is not unlike many complex behavioral interventions that have yet to be offered in routine care (IOM, 2015).

Significant inhibitors of PCC integration persist at the individual provider level despite widespread policy support and clearly operationalized guidelines. Person-centered care planning (PCCP), a manualized intervention, has translated the ideas of person-centered care into a reimbursable, usable, and effective set of practices for community mental health settings and has been widely disseminated across the globe by the champions and scholars of person-centered care (Adams & Grieder, 2004; Tondora, Miller, Slade, & Davidson, 2014). However, providers have expressed concerns related to their own beliefs about the people they serve (e.g., people may not make the best decisions), their roles (e.g., devalues our clinical judgment), perceived contextual barriers (e.g., not consistent with billing requirements), and an optimistic claim that they are already doing it (Tondora et al., 2014; Tondora, Miller, & Davidson, 2012). Such individual provider beliefs about their role or the capacity of someone they are working with have presented significant barriers and have required critical ongoing support to help providers shift how they work with patients.

Additionally, recent evidence suggests that those providers who report the highest use of person-centered care practices actually have the lowest knowledge of mental health recovery – a foundational knowledge base for delivery of person-centered care process (Matthews et al., 2018). Overly optimistic provider self-assessments of practice can inhibit decision-making about the relative advantage of adopting PCCP (Proctor et al., 2011). As providers weigh adopting PCCP, they may need ongoing feedback and support in order to accurately assess if this intervention is different, better, or perhaps easier than what they were previously doing. Engagement in processes to make sense of the change, commit to collectively change within their programs, and ongoing reflexive monitoring of its continued utility for their patients has also been theorized as critical processes for normalizing an innovation (May & Finch, 2009). Addressing such barriers to providers’ learning and practice behavior change are critical antecedents to availability of PCCP into routine care. Evidence suggests that ongoing supports play a critical facilitative role (Beidas, Edmunds, Marcus, & Kendall, 2012) and internal leadership and supervisory relationships are associated with openness to feedback (Fenwick, Brimhall, Hurlburt, & Aarons, 2019).

In community mental health settings, workplace-based supervisors provide both programmatic and clinical oversight. These supervisory positions are tasked with overseeing the quality of patient care and the professional development of clinicians across community mental health settings (Dorsey et al., 2017). As such, clinical supervision is an almost universally available mechanism for quality assurance across mental health care, which makes it a potentially impactful intervention point for translating person-centered care into routine clinical practice. Supervision techniques such as behavioral rehearsal in supervision, which is applying a particular skill or intervention in a role-play scenario, have been associated with higher fidelity to evidence-based practices (Bearman, Schneiderman, & Zoloth, 2017). In an observational study of objectively coded workplace-based supervision sessions, five supervision techniques were considered ‘gold standard techniques’ and they included symptom monitoring, actual review of audio or video recorded practice sessions, assessment of fidelity to treatment techniques, clinician behavioral rehearsal or supervisor modeling of a treatment technique in supervision (Dorsey et al., 2018, p.6). This study, along with two others in children’s mental health settings, found that these most effective, gold standard, supervision techniques are least often used in routine settings (Bailin, Bearman, & Sale, 2018; Dorsey et al., 2018; Schriger, Becker-Haimes, Skriner, & Beidas, 2020). Another observational study found a similar pattern in adult-serving settings with providers rarely reporting having experienced these gold standard supervision techniques in their time with supervisors (Choy-Brown & Stanhope, 2018).

In the context of a PCCP implementation effort that targeted supervisors as the primary disseminators of a new intervention, this study addresses this critical gap in our understanding of how workplace-based supervisors translated new knowledge to providers and supported the adoption of person-centered care across their program. Understanding emic (or insider) perspectives and approaches to fit a translational effort into the practice of clinicians in their programmatic context is critical to inform the development of potential supervision-focused strategies for supporting implementation and sustainment of EBP. Qualitative methods of inquiry are particularly well-suited to advance understanding and explore supervisory interactions with their supervisee providers during a translational effort (Hamilton et al., 2018). Using an implementation science framework, this study aims to further uncover clinical supervisors’ strategies within their interactions with providers to promote the translation of PCCP into routine community mental health services.

Methods

Sampling

A criterion sample of supervisors (N = 12) was selected from the baseline sample of supervisors (N = 81) participating in the parent study, which was a multisite randomized controlled trial testing the effectiveness of Person-Centered Care Planning. Experts delivered tailored PCCP training and 12-months of technical assistance to supervisors. A detailed description of study protocol has been published (Stanhope et al. 2015). Eligibility requirements for this sub-study included the following criteria: a) received training in PCCP; b) expected to implement the PCCP in their programs; and c) were staff members directly responsible for overseeing programmatic services and direct care providers (supervisees). In addition, supervisors had demonstrated engagement in the intervention implementation as measured by consistent attendance to the training and twice monthly consultation calls with the intervention developers. Of supervisors who met these criteria (N=44), a targeted sampling strategy was employed to facilitate a final participant pool representing maximum variation in the alignment between supervisors’ self-assessments and their supervisees’ ratings of the supervisors’ implementation leadership, as measured by a mean total score of the 12-item implementation leadership scale (Aarons, Ehrhart, & Farahnak, 2014). Supervisee providers (N = 22) were purposively selected among staff reporting to the participating supervisors. The baseline survey participants included direct care providers (N=143) who reported to participating supervisors. Supervisee providers included social workers, case managers, and other staff who provided services directly to service users. Inclusion criteria involved adequate exposure to the participating supervisor and the intervention. Supervisors and providers were sampled until sufficient to reach saturation in the data (Miles, Huberman, & Saldana, 2014).

Data Collection

Data sources included both direct observation and interviews from multiple perspectives (i.e., supervisors’ and providers’). The richness of both observation and interviews generated an understanding of processes and relationships within and across real world health service settings (Boblin, Ireland, Kirkpatrick, & Robertson, 2013) and maximized opportunities to identify both convergence and divergence within the data. Convergence in findings between observation, the supervisor perspective, and the supervisee perspective can increase confidence in the trustworthiness of the study’s insights into the social interactions among staff. In addition, identified divergence between data sources can uncover key perspectives and provide further refinements in understanding phenomena (Padgett, 2016).

Direct observation consisted of on-site “shadowing” of supervisors (N=11) on a typical day and observation of usual program activities involving interactions between providers and their direct supervisors (e.g., supervision). These site visits totaled over 65 hours of observation from September, 2016 to April, 2017 and the observational field notes were logged that captured observed social processes, programmatic culture, and climate (Padgett, 2016).

Interviews (N = 34) were semi-structured and were conducted with supervisors and providers regarding their perspectives and experiences of clinical supervision and their practice in the context of the implementation of PCCP into their programs during the same time frame. The interview guides began with general open-ended questions regarding these domains, facilitating an inductive process. This was followed by specific probing questions and findings from the direct observations (Morgan, 2007). Sample questions included: What is supervision like here? What helps and/or hinders using PCCP with service users? Who do you look to for ideas on how to help service users more effectively? Interviews were audio-recorded (with consent) and transcribed verbatim. Atlas.ti software was used for data management and analysis. The author’s university human subjects review committee approved all protocols. The author conducted participant interviews and observations and had limited prior exposure to the study participants through their participation in the parent study trial. While the author had been a part of the research team in the trial, a separate team from a partner institution had been involved in the scheduling and delivery of the PCCP intervention.

Analytic Strategy

Analysis followed a grounded theory and constant comparative approach suited to the systematic and flexible nature of the qualitative methods (Glaser & Strauss, 1967). Constant comparative methods from open coding techniques fostered the identification of similarities and differences in the data and facilitated the development of initial codes, such as strategies and supervision content (Glaser & Strauss, 1967). Two researchers (including author) with experience as providers and supervisors in community mental health settings co-coded transcripts and developed a codebook. Subsequently, the strategies code was extracted and used in more focused coding (Charmaz, 2006). In addition, concurrent thematic analysis of field notes was used for triangulation of participant perspectives of supervisory relationships and contextual factors (e.g., observation of supervisor and provider and their descriptions of supervision). Observation and interview data were further examined in case study matrices to identify confirming and disconfirming data (Miles et al., 2014). Inconsistencies between the multiple data sources are common. Additional strategies for rigor in qualitative research aided in resolution of inconsistencies as well as improving rigor throughout the process including memo writing throughout the data collection and analysis processes, peer-debriefing with the parent trial research team, maintenance of an audit trail of decisions were maintained (Padgett, 2016).

Results

Sample

Participants (N = 34) were supervisors (N = 12) and providers (N = 22) working at community mental health agencies who were trained and implemented PCCP between 2014 and 2017. Represented sites (N = 4) were all located in one northeastern state and program services included community support services (N = 13), young adult services (N = 6), residential (N = 9), and outpatient therapy (N = 6). These participants represented a range of self-assessed implementation leadership with half below and half above the mean of the parent study sample. The majority (N=11) of programs reached an acceptable PCCP fidelity on average post-training. Supervisors and providers were majority female (88.2%), white (66.6%), and held at least bachelor’s degrees (88.2%). They were approximately 41 years old and had been working at their agencies for 8 years on average. Table I presents sample demographics.

Table I.

Sample Demographics (N = 34)

	Total N = 34		Supervisors N = 12		Direct Provider N = 22
	N/Mean	%/SD	N/Mean	%/SD	N/Mean	%/SD
Age	41.4	13.4	46.8	9.2	38.5	14.6
Gender - Female	30	88.2%	11	91.7%	19	86.4%
Ethnicity - Hispanic	3	8.8%	1	8.3%	2	9.1%
Race
White	23	67.6%	8	66.7%	15	68.2%
Black	8	23.5%	2	16.7%	6	27.3%
Othera	3	8.8%	2	16.7%	1	4.5%
Education
Graduate	13	38.2%	5	41.7%	8	36.4%
Bachelors	17	50.0%	5	41.7%	12	54.5%
High School	4	11.8%	2	16.7%	2	9.1%
Employment Tenure (years)	8.0	7.9	10.8	8.8	6.5	7.2

^aParticipants selected ‘other’ response option. No other categories were collapsed into this one.

This qualitative inquiry from multiple sources was conducted to understand supervisory strategies to promote providers’ adoption of PCCP. Three primary themes arose: knowing your audience, chipping away, and practicing together. Knowing your audience focused on the supervisor-provider interactions and the importance of attunement to providers’ emotional and learning needs. Chipping away highlighted the work supervisors employed to implement the practice, including operationalizing the behavior change, staying vigilant over time to meet challenges, and infusing reminders for providers in their interactions. Lastly, practicing together focused particularly on the use of in vivo and ad hoc supervision to facilitate learning and buy-in for practice change. Supervisors and providers expressed the importance of these supervisory strategies for their adoption of this new PCCP approach to their treatment planning.

Knowing Your Audience

One supervisory strategy viewed as critical to providers’ adopting PCCP was knowing your audience. Participants shared that the supervisors’ ability to attune to the provider’s immediate and long-term needs was critical to their translational efforts. One supervisor participant shared, “my biggest strategy is knowing my staff and knowing how they’re gonna react, using the right words, understanding who they are … knowing your audience because that’s how you get the best out of people” (Supervisor #167). Participants shared that this strategy optimized their ability to accurately respond to differences in providers’ experiences of barriers to PCCP use. As this supervisor shared, “I can’t supervise everybody the same way and I really have to modify and adjust my style based on the needs of my staff” (Supervisor #169).

Specific tactics to facilitate knowing their audience included increasing the frequency of their interactions and opportunities for observation of providers. One supervisor shared that she positions herself proximal to providers to foster a higher frequency of interactions: “If they walk by my door and they have that look, I’m like what’s going on, you know. You get to know your staff pretty well and can breathe when they’re struggling with something and talk to them about it” (Supervisor #169). Another strategy was to increase flexibility within supervision time to build in additional opportunities for providers to process individually and collectively. She stated, “I’m taking a step back and hearing everybody’s position. So I find myself trying to be like the active listener for the themes of things” (Supervisor #197). This additional time informed assessments of needs and an outlet for provider to voice their perspectives. Providers described that supervisors’ keeping an “open door” provided ad hoc opportunities for guidance about “what can we do or how do we handle this” (Provider #293) as questions arose in real time. This accessibility allowed invaluable opportunities for in vivo supervision feedback and direct observation of providers’ enactment of PCCP. The importance of ad hoc accessibility was also highlighted in the divergence of experiences between one supervisor and supervisees. The supervisor (#304) shared their perspective that attuning to staff needs was a critically important strategy, yet, supervisees on that team consistently reported experiences of being unheard and low buy-in. Field notes confirmed observations including low proximity of the supervisor’s office to the supervisees’ workspace and very limited supervisor-supervisee contact.

Participants also described building a sense of collective responsibility for providing feedback and support to providers. Supervisors used their observations and provider feedback to inform their expectations of PCCP implementation outcomes. One participant found that providers were not moving at the same pace, “Some of them have changed, some of them haven’t really. . . . [with] all the other demands, I don’t think they [all] take it as seriously as maybe some” (Supervisor #177). Whether it was motivation, available resources, or a particular belief presenting as a barrier, supervisors used this strategy of knowing their audience to inform their response. Another supervisor acknowledged, “that’s the biggest part of my supervision, really knowing my audience, who I’m talking to, how they’re gonna respond to [my] critique” (Supervisor #167). At times, supervisors reported buffering and slowing the pace so as not to overwhelm already burdened staff. One supervisor stated, “I love this way of doing things [PCCP], I totally do, but . . . . I’m not even putting that on [the staff] yet” (Supervisor #304). Another supervisor participant shared, “I know my staff well enough to know when they’re having good days, bad days or they’re checked out” (Supervisor #284). By attuning, supervisors could efficiently use their time to support providers to overcome a presenting barrier to using PCCP.

Knowing their audience also helped supervisors to facilitate motivation for less desirable, but necessary implementation activities, including receiving constructive feedback. One provider participant shared their positive experience of learning the new PCCP use of the electronic health record system: “She’s [the supervisor] really good about making it like not miserable. . . . . I feel like it almost makes the transition into these new systems a little bit easier” (Provider #169). Some participants appreciated when supervisors paired activities with food. Others acknowledged the importance of how supervisors provided the feedback about their integration of PCCP. One provider shared about her experience of receiving feedback,

[the supervisor] “offer[s] suggestions, but never makes you feel like, you know, what you did was wrong.

... She gets to really know us and kind of like what we’ll respond well to, what we won’t really respond well to and I think that’s important. . . it’s not one of those relationships where you fear being called into your supervisor’s office” (Provider #169).

Providers reported that these positive experiences helped them experiment with and learn to use the new PCCP approach to their treatment planning.

Chipping Away

The theme of chipping away encompasses supervisory strategies to infuse their interactions with providers with reminders and prompts for practice change. Supervisors described two different approaches to this strategy. Some supervisors described identifying opportunities as their providers’ presented them and using those windows to impart PCCP-related feedback. One supervisor described that her process is to,

“just chip away and be mindful when it’s happening and being flexible and adaptable to intervene at any place when you see it happening, calling it out in a respectful kind of way, you know, like I see your punitive measure and I raise you a person-centered bar” (Supervisor #197).

Some of the ways this supervisor described enacting this process was “just noticing them” and saying things to providers such as, “if I have to be truthful with you, I’m hearing a lot of correctiveness here,” which she described as constructive feedback “in a kind of gentle, not always gentle way” (Supervisor #197). Other supervisory participants also tried to be “super supportive, but I’m not afraid to confront them either” (Supervisor #169). Observations of supervision sessions confirmed supervisors’ use of this strategy as supervisors challenged providers’ beliefs that were contradictory to PCCP as they arose in the conversation.

Others described a different approach to chipping away at the required practice changes. Instead of staying vigilant to interpersonal opportunities for observation and feedback, a supervisor described focusing her reminders on written feedback based on providers’ treatment documentation. During participation observations, large stacks of papers were observed on her desk and the supervisor (#165) shared her strategy to read every chart and, “it’s just pounding it into everybody’s brain.” She shared that in her experience this strategy works to change practice. She stated, it’s “much better now because we’ve been harping on it and going over it. . . . they’re getting them [charts] back. I’m like sorry and they’re getting my little sticky notes and I’m like you forgot the person-centered blurb in there” (Supervisor #165). Across the interviews, supervisors acknowledged helping providers to initiate, learn, and integrate PCCP required tremendous effort and that this ongoing monitoring and feedback was critical in helping providers make changes to their routine practice. Provider participants also described that their supervisors’ efforts to provide opportunities to problem-solve using PCCP in different scenarios was very important to strengthening their skill development and motivation to continue using it.

As these examples describe, supervisors varied in both how they chose to translate PCCP and what PCCP training content was prioritized in their prompts for providers. These examples illustrate supervisors’ strategies to chip away at PCCP integration by providing written or oral feedback, reviewing documentation, or the vigilant search for learning opportunities to allow for real time problem-solving the application of PCCP and in vivo supervision. These strategies also signal supervisors’ differential sense-making of the critical pieces of the complex intervention for their particular settings. One supervisor (#167) described her process of “picking and choosing the parts of these initiatives that are going to be helpful.” Interviews included supervisory descriptions of the context (e.g., competing demands) and the individual provider factors (e.g., beliefs) that influenced how and what they emphasized during their time with providers.

Practicing Together

Using planned and ad hoc supervision time to practice PCCP together was another critical component of the supervisory translation process. Active engagement between supervisors, providers, and the practice provided opportunities for modeling, observing, and refining their PCCP practice. In addition to building providers’ capability, this hands-on experimentation and practice communicated enthusiasm for, and expectation of, PCCP use, as well as facilitating shared firsthand experiences of implementation challenges. In this implementation effort, supervisors were also new users of PCCP and this collaborative learning and practicing afforded them opportunities to both model how to deliver and how to receive constructive feedback in addition to actual practice delivery. Among some teams, supervisors fostered a multidirectional constructive feedback process with opportunities for constructive feedback from both supervisors and providers. Participants described the utility of supervisors being “able to engage in courageous conversations” (Supervisor #289) and stated that providing and receiving constructive feedback helped create a culture supportive of learning. Another supervisor described,

“I don’t want them to feel like I’m in some like ivory tower going I am the sage wisdom on top of mount [program name], you know, because I will screw up plenty of times and I get it wrong and I’m human and I think they need to see that” (Supervisor #197).

For these supervisors, this process was about teaching providers about both their expectations broadly and the new practice.

Participants provided descriptions of practice collaboratively with providers, expressing the belief that, “if I’m going to expect that you can do it, I’m gonna show you that I can do it too” (Supervisor #304). In addition, this supervisor shared that a hands-on approach supported providers in using the new practice, stating, “if I’m not doing it, then they’re not gonna do it, and I’m excited about it, then they’re excited about it” (Supervisor #284). Participants experienced growth in motivation and confidence within active collaboration from supervisors. A supervisor shared that “breaking the pattern of behavior” really took, “checks and balances. I check staff as well as they check me” (Supervisor #289). Another supervisor used consistent praise and reassurance to aid providers’ motivation as they faced learning obstacles, stating, “I try to champion as I go along and I let them know we can do this, let’s keep the course. . . . keep the hope alive … we’re going through storms right now, but, you know, clean clear waters were coming” (Supervisor #295). Once engaged, providers were able to experience, with supervisors, the benefits of the new intervention, which further motivated practice change.

These shared experiences also fostered shared first-hand knowledge of implementation challenges in real time. One provider participant described, “our frustrations are typically hers too because she’s out there doing it, you know, she’s doing the same thing we are you know” (Provider #169). Supervisor participants shared their perspectives that this level of engagement made them more effective and efficient in navigating challenges. This supervisor described, “I know what my clinicians are going through. I know how to fight the system here. It can be brutal at times … we do that so that we know what’s going on” (Supervisor #165). The shared experience also allowed for learning by using real life experiences in tandem with applications as tools. Provider participants described positive perceptions of supervisors who engaged in this collaborative practice. Supervisors who engaged in this daily reality with providers were described as being real, approachable, and credible by provider participants. Participants described these collaborative experiences as building the supervisors’ credibility and aiding in their motivation to facilitate supervisors’ priorities. In contrast, where supervisors did not engage in this strategy, participants described a distance from supervisors as well as misunderstandings of providers’ PCCP experiences.

Discussion

These findings begin to unpack the black box of the ways in which supervision time can be used to promote the use of new practices in community mental health care. Participants and observations characterized three practice-based supervisory strategies that were used to foster providers’ adoption of PCCP during this implementation effort. Each strategy delineated how the available formal and informal time supervisors and providers spent together in workplace-based supervision in order to facilitate the implementation process. The strategies included: 1) supervisory attunement and assessment of providers capacity, motivation, and skill development informed the efforts to promote PCCP use (knowing their audience); b) efforts to remind, provide real time feedback, and reward PCCP use in their interactions with providers (chipping away); and c) facilitation of a collaborative learning environment with opportunities for active learning techniques, navigating barriers, and supporting PCCP use (practicing together). These strategies each represent discrete tactics that supervisors across the sample employed in differing ways. While the supervisors shared the same goal to promote PCCP use, the variation in how they employed these strategies may signal their underlying theory of change and understanding of why and what supervisee providers needed to integrate PCCP. Supervisors’ considerations and decision-points in employing these strategies, and providers’ descriptions of their experiences with their supervisors are critical perspectives to understand how available workplace-based supervision time is used to promote new practices.

Notable in these findings is how supervision time provided a naturally occurring infrastructure that shaped how providers fit the required change into their individual practice contexts and their commitment to engaging in the effort. These provider activities have been identified as critical antecedents to implementation outcomes (May et al., 2009). Higher accessibility to this supervision time provided a ready-available resource for providers and supervisors that informed needs assessments, provided opportunities for feedback, and communicated support as providers grappled with using PCCP with people seeking services in their programs. In addition, participants described the use of best practice supervision techniques (i.e., modeling, behavioral rehearsal, and observing clinical interactions) infused through this supervision time and suggest concrete strategies to infusing these active learning strategies in ways that are perceived positively (Dorsey et al., 2018; Milne & Reiser, 2012). For example, the techniques were used during ad hoc time when supervisors’ open doors allowed them to directly observe interactions and potentially intervene to model PCCP process. In addition, the real time, ad hoc feedback and modeling as supervisees encountered implementation challenges were reported. This time also informed the supervisor-provider shared understanding of what that provider needed in order to enact PCCP initially and for them to continue to integrate it into subsequent clinical encounters.

Findings from this study also contribute participant descriptions of a reciprocal exchange between supervisors’ use of particular strategies and providers’ motivation and effort towards an implementation outcome. Participants described that when providers experienced support and individualized consideration for their work and for them as people, they repaid those experiences in improved performance. This is consistent with social exchange and leader-member exchange theory (Schriesheim, Castro, & Cogliser, 1999; Zhou & Schriesheim, 2009) and previous findings of associations between the presence of a reciprocal exchange and attitudes towards evidence-based practices (Fenwick et al., 2019). Harnessing this reciprocity during the translation of PCCP was described as helpful to the efficient use of supervision to build providers’ motivation for PCCP adoption. Indeed, supervision research has found that the quality of supervisory relationships have mitigated barriers to practice change in previous research (Lloyd, Boer, & Voelpel, 2017).

These supervisory strategies cultivated positive experiences in supervision broadly and specifically helped supervisors to fulfill their roles as the translators of PCCP. With accurate attunement, supervisors were able to speak fluently to providers’ individual and collective motivations for implementing PCCP whether it was addressing their underlying beliefs (e.g., bias related to a service user) or navigating through a pernicious contextual barrier (e.g., the electronic health record). Within the community mental health contexts, these efforts enhanced the supervisors’ abilities to mediate these day-to-day challenges and to sell PCCP to providers, which may have positively influenced providers’ perceptions that using PCCP was expected, supported, and rewarded in their teams (Birken, Lee, & Weiner, 2012; Bunger et al., 2019). This is consistent with other research that has found a significant association between EBP-related supervision content and implementation climate for change (Pullmann et al., 2018). Provider participants described supervisory fluency with their needs combined with their enthusiasm or persistence for PCCP shaped their perceptions and decisions to adopt PCCP. Indeed, supervisors varied in how they used their supervision time to anticipate and support their teams to persevere through obstacles and promote PCCP use. Such supervisory discretion in whether and how they use these strategies to harness supervision time could have implications for the successful adoption of new practices, particularly when supervisors vary in their buy-in to the initiative.

Additionally, these interconnected supervisory strategies demonstrated that supervisors and their clinical supervision time can be a critical intervention point to promote new practices, and particularly, if those practices provoke individual-level barriers to implementation. Supervisors have potential to be an ideal facilitator of EBP when they harness their formal authority, interpersonal influence, and proximal position. How supervisors use their positions was perhaps important to providers’ descriptions of their experiences. When supervisors cultivated a climate of “practicing together,” where providers felt that their supervisor “knew their audience,” provider participants described their supervisors less as distant formal authorities and more as “near peers” with greater knowledge credibility. This credibility encompassed what Rogers (2010) distinguished as safety and knowledge credibility. In addition, supervision was experienced as a space for sharing mistakes and receiving constructive feedback. These supervisory strategies seemed to cultivate engagement, flatten interpersonal power dynamics, and strengthen supervisors’ interpersonal influence, which facilitated provider adoption of PCCP. This use of the supervisory relationship, engagement in collaborative learning, and efforts to explicitly target power in their relationship mirror elements of the PCCP process, which may have further modeled and reinforced PCCP for providers. While supervisor-supervisee and provider-service user relationships are distinct in important ways (e.g., supervisors are not providing clinical services), the influence of parallel processes within these relational interventions may be a promising target to further support the use of PCCP.

Limitations

While this study combined multiple perspectives, which is a significant strength, findings should be considered in the context of limitations. Supervisor-provider interactions are dynamic and subject to a potential recency bias such that participants’ most recent experiences in supervision may have led to a misrepresentation of those interactions overall. In addition, this study employed a retrospective examination of the phenomena from one time-point and included self-reported participant perspectives about their experiences. A significant strength of this study is the triangulation of a criterion sample (informed by quantitative data) of participant perspectives with direct observation of their supervisory activities and interactions with provider. However, it should also be noted that observations were based on one observer (author) and these strategies were not linked to their degree of association of adoption.

Conclusions

This formative work has contributed to the understanding of strategies used within workplace-based clinical supervision to support PCCP translational efforts. This available time between providers and their supervisors may represent a critical link between implementation efforts and routine availability of efficacious care that considers the personhood of people seeking services. This study characterizes how multifaceted supervisory strategies engage providers in the necessary activities for examining their biases and learning new approaches to care. Within these supervisory interactions, proactive implementation leadership was necessary, but not sufficient to support provider PCCP adoption. A collaborative practice climate and attuned supervisory relationships provided the context necessary to motivate and engage providers in the difficult work of practice change. These strategies changed providers’ practice patterns by improving supervisors’ calibration to dynamic contextual and individual needs during implementation and communicating supervisors’ expectations of PCCP enactment. Strengthening the naturally occurring supervision infrastructure within community mental health settings has powerful potential to be a low cost and potentially high yield intervention point to support the routine delivery of person-centered care.