Clinician’s Commentary on Snowdon et al.

Clinical education remains an important part of both undergraduate and postgraduate physiotherapy programmes around the world. In clinical education, students learn clinical skills by being exposed to real-world clinical scenarios, and then they apply the theoretical knowledge and skills they have developed in the controlled classroom environment with patients under the tutelage of a clinical supervisor. Not only do students develop and refine their skills, but they also learn, develop, and refine their professional behaviors.

The importance of clinical supervision for physiotherapy students has been well reported in the literature; however, the role of clinical supervision for qualified physiotherapists remains less well explored, despite widespread recognition of its importance in standards and guidelines. Snowdon and colleagues explored physiotherapists’ perceptions of clinical supervision using a mixed-methods approach.¹

The role of clinical supervision in the professional sphere is to ensure that standards of patient safety and quality of care are maintained under the guidance of a clinical supervisor. As with student clinical supervision, the scope of supervision for qualified physiotherapists covers the formative, restorative, and normative domains of practice.

In the formative domain, clinical supervision helps physiotherapists develop specific clinical skills, usually at a more advanced level than with student physiotherapists. It requires that these physiotherapists recognize that their clinical supervisor has advanced skills. In the nursing literature, the value placed on the formative domain is inversely related to the years of nursing experience, with new graduates valuing it more highly than experienced nurses.²

In the restorative domain, a clinical supervisor has more of a collegial role, supporting physiotherapists as they express their thoughts and emotions about their professional role and providing a debriefing opportunity. In this domain, the clinical supervisor is seen as a peer who provides validation and support through peer feedback.

In the normative domain, clinical supervision supports physiotherapists as they comply with standards of care and organizational policies and procedures. This is a policing or auditing role that aims to ensure that physiotherapists meet the standards of care and patient safety.

Clinical supervision in hospital departments can occur in a variety of ways – using a reflective model of supervision, a model of direct supervision, or a combination of both – however, the evidence remains unclear about which model is most effective or, more broadly, about whether clinical supervision is actually effective at all. Snowdon and colleagues found that clinical supervision was reported to be ineffective by more than 50% of physiotherapists,³ and Gardner and colleagues found that physiotherapists reported on average that clinical supervision was ineffective.⁴ More research is needed to identify what makes clinical supervision in physiotherapy effective.

Snowdon and colleagues used a mixed-methods study design to explore what aspects of clinical supervision physiotherapists believed effectively supported them in their professional role.¹ The authors used semi-structured interviews with 21 physiotherapists from a public hospital to explore their experiences with clinical supervision and the aspects of the supervision that the physiotherapists considered to be effective. They also conducted a concurrent quantitative descriptive survey using the Manchester Clinical Supervision Scale (MCSS–26) to document the effectiveness of clinical supervision. The MCSS–26 was developed by Winstanley in 2000 and reported to be the most well established, internationally validated questionnaire to measure the effectiveness of clinical supervision. The original tool was revised from 45 questions to 26 questions (hence the 26) and has been shown to correlate to Proctor’s three domains of clinical supervision.⁵

Snowdon and colleagues used purposive sampling to reflect the diversity of the profession:¹ they investigated a range of levels of seniority (grade 1 [junior], grade 2 [mid-level], and grade 3 or 4 [senior]), areas of practice (acute hospital wards, sub-acute [rehabilitation] wards, emergency departments, hospital outpatient setting), and specialties (geriatric evaluation and management, cardiorespiratory, orthopaedics or musculoskeletal, neurology and general).

Physiotherapists reported that clinical supervision was most effective when it used a direct model of supervision, one in which their supervisor directly observed and guided their professional skill development. They also reported that opportunities for informal supervision were effective when issues were dealt with as they arose in discussions with their supervisors and when the supervisors who valued supervision provided guidance. Clinical supervision driven by the physiotherapists’ individual learning needs was valued more highly than generic supervision practices driven by organizational processes.

Given the current drive to ensure that clinical physiotherapy services are provided using an evidence-based approach, and because these services are often provided in an environment in which fewer resources are available for non-clinical services, it is paramount that we ensure that the resources spent on these non-clinical services are maximized. Clinical supervision, although promoted by national professional standards, is commonly viewed as a non-clinical service, and it is considered resource intensive because it requires at least two staff members and may involve time away from patient care. It is therefore important that the profession explore what works and does not work most effectively in clinical supervision. Taking a client-centered approach by exploring, from the physiotherapist’s point of view, what works and what does not is an ideal start, but it is important that it not stop here.

As a profession, physiotherapy needs to ensured that the processes physiotherapists implement to improve quality of care actually make a measurable change to that quality of care. Clinical supervision is theoretically a valuable process that can reduce the variability in patient care, thereby maximizing patients’ safety and health outcomes. However, as with much evidence-based practice, the effectiveness of certain evidence-based interventions has not necessarily been shown. Measuring change in patient and therapist outcomes after implementing clinical supervision will help the profession continue to argue for its importance and professional development.