Does Clinical Supervision Impact Supervisee Competence in Clinical Practice

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Abstract

Clinical supervision is a key factor in the professional development and competence

of the supervisee. The recent shift towards competence-based practice has

highlighted a need to understand the relationship between supervision and

supervisee competence further. A systematic review following PRISMA-P guidelines

aimed to summarise and synthesise the literature across five databases exploring

the impact of supervision on supervisee competence and the factors that may

contribute to effective supervision. Eleven papers met the search criteria and were

included within the review. A narrative synthesis of the findings provided some

evidence of a positive relationship between supervision and supervisee competence

with feedback and the supervisory relationship shown as important factors. The

implications for future research and practice are discussed.

Keywords: competence, supervision, supervisee, systematic review

Introduction

Clinical supervision is viewed as an essential part of clinical training and

clinical governance across health professions (Roth & Pilling, 2007; Watkins, 2011).

There are numerous definitions of the function of supervision in clinical practice.

These broadly address the professional development and competence of the

supervisee through risk and case management in order for safe and effective

practice (Bernard & Goodyear, 2014; Falender & Shafranske, 2004; O’Donovan,

Halford & Walters, 2011). Although the definition of competence varies depending

on the context, it is broadly understood to encompass the development of

knowledge, skills and attitudes (Kaslow et al., 2004).

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Supervision is viewed as a valued part of clinical training (Scott, Pachana &

Solranoff, 2011; Wilson, Davies & Weatherhead, 2016). Scott et al. (2011) conducted

a survey of clinical psychology programme directors and postgraduate students in

Australia reporting supervision to be rated by both as essential in the student’s

training and development. The survey found self-report of perceived competence

was the most frequently used method to assess the trainees’ clinical work whilst in

training. In addition, research has reported the role of supervision in contributing to

improved supervisee emotional wellbeing, therapeutic awareness and confidence in

ability (Bernard & Goodyear, 2014; De Stefano et al., 2007; Vallance, 2004).

The evaluation of supervisee competence has been recognised to occur

primarily through verbal discussion between the supervisor and supervisee (Falender

& Shafranske, 2004; Tweed, Graber & Wang, 2010). A need for effective ways to

measure a supervisee’s competence has been acknowledged in the recent

development of the University College London competence frameworks (UCL, 2019).

These frameworks set out specific competences for individuals to develop

knowledge and skills relevant to specific models of therapy and clinical populations

(UCL, 2019). In addition, more structured psychometric measures such as, the

Cognitive Therapy Scale- Revised (CTS-R, Blackburn et al., 2001), the Clinical Skills

Assessment Rating (CSA-R, Tweed et al., 2010), and the recent Systemic Practice

Scale (SPS, Butler et al., 2018) are all used to assess competence within the context

of cognitive behaviour therapy (CBT), clinical psychology and systemic practice

respectively.

The purpose of assessing an individual’s competence is to provide helpful,

meaningful and constructive feedback for the individual to reflect on their clinical

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

skills and highlight possible areas of development. Clinical supervision is argued to

aid the development of competencies in clinical practice, however the specific

aspects of the supervisory process associated with this are still not well understood

(Falender & Shafrenske, 2004; Milne, 2007; Stolenberg, 2005).

Wilson et al. (2016) completed a qualitative meta-synthesis of trainee

therapists’ experiences of supervision during training. They described supervision as

an opportunity for learning and reiterated the importance of the supervisory

relationship in facilitating this process. Heckman-Stone’s (2004) review of the

literature indicated feedback and evaluation to be effective in producing change in

supervisees’ practice, facilitated through a supportive supervisory relationship.

Research supports the importance of the supervisory relationship in the success of

supervision (Ladany, Ellis & Friedlander, 1999; Kilminster & Jolly, 2000). Kilminster

and Jolly’s (2000) review of supervision in clinical practice settings found the

supervisory relationship and clear feedback to be the most important factors for the

supervisees in their development.

Gonsalvez, Hamid, Savage and Livni (2017) suggest the effectiveness of

supervision is evaluated at two levels, “first-order supervisee levels (e.g. extent to

which supervisee competence is enhanced) and at second-order, flow on effects on

client outcomes (individual/family/organization) deriving from both supervisor and

supervisee competence” (p. 96). Previous reviews in the area have focused on the

role of supervision, competence and client outcome (Milne & James, 2000; Watkins,

2011; Wheeler & Richards, 2007). Milne & James (2000) found some support for a

positive effect of supervision and supervisee competence in CBT and client outcome.

The effect was noted through supervisory methods that included feedback, modeling

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

and idiosyncratic instruction, however methodological issues with both the review

procedure and the studies included meant the findings were weak and inferences

from these findings were limited. Wheeler & Richards (2007) conducted a systematic

review of literature examining the impact of clinical supervision on counsellors’ and

psychotherapists’ practice and their clients. The quality of the evidence varied but

supervision was regarded to have a positive impact on the supervisee’s

development.

More recently Alfonsson, Parling, Spannargard, Anderson & Lundgren (2018)

conducted a systematic review that explored the effects of clinical supervision on

supervisees’ competences and clinical outcomes in CBT. They found limited

research supporting the positive effects of clinical supervision on therapist's

competence in CBT. The review highlighted several methodological limitations

including poor study designs and a need for better conceptualization and measures

of supervision features. Specific formats of supervision such as video monitoring

however showed promising findings at improving the psychotherapist’s competence

and patient outcomes but the research in this area is limited (Alfonsson et al., 2018).

Although considerable research has been conducted on models of supervision

theory (Falender & Shafranske, 2004) there appear to be gaps in rigorous systematic

reviews of the area of supervision and supervisee competence. It is hoped if

supervisee competence improved inevitably this would have positive clinical

implications for clients (Roth & Pilling, 2007).

Rationale

The importance of supervision in clinical training is well established (Falander

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

& Shafranske, 2004; O’Donovan, Halford & Walters, 2011). There has been a shift

towards competence-based practice and the need to measure competence of

clinicians in clinical practice has been highlighted (Butler et al., 2018; Roth & Pilling,

2007). Some have argued the need for high quality empirical evidence that

examines the relationship specifically between supervision and supervisee

competence as a specific outcome (Bambling et al., 2006; O’Donovan et al., 2011).

Previous research has evidenced the importance of supervision in supervisee

development (Heckman-Stone, 2004; Kilminster & Jolly, 2000; Milne & James, 2000;

Wilson et al., 2016; Wheeler & Richards, 2007). However there appears to be limited

research which focuses specifically on the relationship between supervision and

supervisee competence; highlighted as a recommended area of future research in

the meta-synthesis of trainee therapists’ experiences of supervision (Wilson et al.,

2016) and in the recent systematic review conducted by Alfonsson et al. (2018).

Alfonsson and colleagues examined the effects of clinical supervision on supervisee

competence in CBT and patient outcomes, finding some evidence to support the role

of supervision in competence development whilst also highlighting the need for

further empirical literature.

The current review aims to extend the work of Alfonsson et al. (2018) which

focused solely on the model of CBT. The current review has no restrictions on the

therapeutic model of practice and specifically focuses on the outcome of supervisee

competence and not the impact of supervision on client outcomes, which has

previously been well researched (Milne & James, 2000; Watkins, 2011; Wheeler &

Richards, 2007).

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

The definition of both concepts of supervision and competence can vary

depending on the therapeutic model or client group which can mean they are difficult

to define and measure. Therefore, for the purposes of the present review a broad

definition of clinical supervision was used, to include individual and group

supervision, face-to-face or other means of communication, e.g. telephone. There

were no restrictions on the model of supervision used. As there are few standard

measures for evaluating psychotherapy supervision, like Alfonsson et al. (2018) a

broad range of outcome measures were accepted to include the attitudes and

experiences of supervisees and their competence development. Similarly, the

definition of competence for the present review was also broad, to include any

reference to the supervisees perceived (self-reported) or observed competence

within their clinical work (e.g. measured through a psychometric scale).

In order to capture the development of competence in supervisees,

participants included are those deemed to be trainees in the therapeutic model of

interest however, the review did not exclude supervisees who were also qualified

therapists in other therapeutic models.

Aim of Systematic Review

The aim is to provide a systematic review of the literature that explores the

relationship between clinical supervision and supervisee perceived and/or observed

competence in clinical practice. The review focused on the impact supervision had

on supervisee competence not evaluated through patient outcome.

The review aims to contribute to and extend reviews in the field of clinical

supervision as described previously by broadening the inclusion of the therapeutic

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

approach and type of supervision used, with specific focus on the outcome of

supervisee competence. This to the best of our knowledge is the first paper to

systematically review this area in such a way.

Literature review questions.

Does clinical supervision impact supervisee perceived and/or observed

competence in clinical practice?

What factors contribute to effective supervision in the development of

supervisee competence?

Method

The review was conducted following guidelines proposed by The Preferred

Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P,

Moher et al., 2015). Studies looking at the relationship between supervision and

supervisee perceived and/or observed competence were examined in this review.

Eligibility Criteria

The PICOS (Population, Intervention, Comparison, Outcome, Study type)

framework was used to screen for the eligibility of study characteristics (Table 1) as

recommended by PRISMA-P (Moher et al., 2015). Table 1 summarises the inclusion

and exclusion of eligible studies.

Table 1.

Inclusion criteria

Exclusion criteria

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

PICOS Framework for the Inclusion and Exclusion of Studies within the Review

supervision on perceived or

observed competence.

Supervisory factors that impact

trainee therapists perceived or

observed competence

trainee therapists’ experience

of clinical supervision and

perceived or observed

competence.

Study type

Peer-reviewed articles

Primary research

Qualitative research articles

Quantitative research articles

Editorials

Opinions or discussion pieces

Books/book chapters/policy

documents/web pages/book

reviews

Articles that have not been

published in English or where a

translation cannot be accessed

Non-peer reviewed articles.

Population

Trainee therapists, trainee

practitioners including

psychology post graduates.

Therapists training in a particular

model. No specific level of

training/competence specified.

Not gender specific

No date restriction

Non-clinicians (e.g. those

whose only role is

nonclinical)

Trainee role is not within the

mental health profession.

Intervention

Clinical supervision of trainee

therapists (to include all modes of

supervision; group, individual,

video, online)

No reference to clinical

supervision on trainee

therapist competence

Comparison

N/A

Outcome

Trainee therapist experience of

Outcomes unrelated to

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Search Strategy and Information Sources

The search strategy was created in consultation with researchers and

clinicians and contained keywords that were combined with Boolean operators to

optimize the search strategy (Higgins & Green, 2011).

The following search terms were used to search across the databases.

1. (Trainee therap*) OR (Trainee Psycholog*) OR (Trainee Practitioner*) OR

(Psychology practitioner*) AND

2. (Supervis*) OR (Clinical Supervis*) AND

3. (Competence*) OR (professional competence*) OR (Experience*) OR

(Perception*)

Databases were searched from inception to October 2018 these included:

PsycINFO, Medline, CINAHL, Applied Social Science Index and Abstracts (ASSIA)

and Web of Science. Amendments were made to the search strategy depending on

the database. For example, proximity operators such as “adj2” and “near” were used

within PsycINFO and ASSIA to increase the sensitivity of the search strategy

(Appendix A).

As recommended by National Institute for Health and Care Excellence (NICE)

guidelines (2012) the included publications’ references lists were hand-searched to

ensure no relevant papers had been missed. Journals screened included The

Clinical Supervisor, Clinical Psychology and Psychotherapy and The Journal of

Clinical Psychology. Grey literature was not considered within this review due to the

time restrictions of the study. All citations were stored on the electronic bibliographic

database EndNote.

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Screening and Data Extraction

Titles and abstracts were screened based on the inclusion and exclusion

criteria (Table 1) and any duplicates were removed. Figure 1 displays the screening

process. At this stage of screening, six papers were randomly selected and

doublerated blind by a second rater to ensure reliability for the inclusion and

exclusion criteria. Disagreements were resolved through discussion. One paper was

discussed and inclusion criteria were clarified therefore 100% inter-rater reliability

was achieved.

Data were extracted from the full texts and summarised (Table 2).

Appraising the Quality and Risk of Bias of Selected Studies

As recommended by the Centre for Reviews and Dissemination (CRD, 2009)

eligible texts were reviewed in full and assessed for quality and risk of bias (n=11;

Table 2). Three of the included studies used mixed-method designs. In these

instances, the quality tool was selected depending on the predominant research

design of the study.

The Quality Assessment tool for Quantitative studies was used to assess

quality and risk of bias of quantitative articles (n=9; QATQS; Appendix B; Effective

Public Health Practice Project (EPHPP), Thomas, Ciliska, Dobbins & Micucci, 2004).

Each article was rated for quality across six components: A) selection bias, B) study

design, C) confounders, D) blinding, E) data collection methods, and F) withdrawals

and dropouts. Each component was scored as strong, moderate or weak, with an

overall rating given. At this stage two of the included quantitative studies were

double-rated blind for quality. Inter-rater reliability was 100%.

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Qualitative articles were assessed using the Critical Appraisal Skills

Programme (CASP) assessment tool (n=2; CASP, 2013, see Appendix C). The

CASP comprises of 10 questions to address the rigour and relevance of the research

where a score from 0 – 3 was assigned depending on the presence of the criteria

being assessed. The scoring was completed by CP and 1 qualitative study was

double-rated blind, inter-rater reliability was 100%.

Studies were not excluded based on the quality of the assessment but

contributed to the overall discussion of evidence.

Method of Data Synthesis

In line with the synthesis of data presented in Alfonsson et al.’s review (2018),

it was expected that the included studies’ results will not be comparable due to

differing outcome measures and analyses and therefore a meta-analysis not

applicable. A narrative synthesis of the findings will be presented and where

appropriate, effect sizes, using Cohen’s d.

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Results

Results of the Search

From the database and journal searches, 779 potentially relevant records

were identified (Figure 1). After removal of duplicates (n=136), the titles and

abstracts of 643 records were screened, of which 609 records were removed. The

most frequent reasons for exclusion after full-text screening are outlined in Figure 1.

Full text articles of the remaining 34 records were assessed for eligibility, of

which eleven articles met inclusion criteria and were included within the review

(Table 2). The study numbers included in Table 2 are used throughout the results and

discussion sections to correspond to the study.

The included studies were heterogeneous in aims and quality. All included

articles explored the impact of supervision processes on supervisee competence in a

therapeutic context. Studies were published between 2004 and 2017, suggesting a

relatively recent body of research. The following section will first describe and

compare the study characteristics before considering the quality of the included

studies. The main findings of the review will then be presented.

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Figure 1. PRISMA flow diagram

Study Characteristics

The characteristics of the eleven included studies are summarised in Table 2.

A brief summary of the differences in the study characteristics are presented in the

following section.

Records identified through database search:

PsycINFO, OVID (n= 521)

Medline EBSCO host (n=34)

CINAHL (n=60)

ASSIA (n=59)

Web of Science (n=94)

Records screened after duplicates removed

(

n=643)

Records removed after title and abstract

screening (n = 609)

Full text articles assessed for eligibility

n= 34)

(

Full text articles excluded, with reasons (n =

23)

•

Commentary papers/reviews

•

Record n

ot a journal article

•

Does not examine competence and

supervision processes

•

Sample not clinicians/therapists

•

Non

English

Additional records identified through other

sources:

(

= 11)

Articles included in systematic review

(

n= 11)

Total records

dentified (n=779)

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

The majority of studies used quantitative designs (1, 2, 5, 7, 8, 9, 10, 11), with

the remaining utilising mixed-methods (3, 6) or qualitative (4). The studies were

broadly based in the UK or US (1, 2, 3, 4, 5, 6, 8, 10), with one based in Germany

(11), one in Sweden (7) and one in Russia and Ukraine (9). Sample sizes were

relatively small across the majority of included studies ranging from 7 to 73, although

two studies had larger sample sizes of around 300 participants (6, 7).

Although all studies reported on the therapist experience of supervision on

perceived or observed competence, this was not always the primary outcome of the

study.

There were variations in the type of therapists that participated in the studies,

although as previously discussed all were trainees or novices within the therapeutic

model being explored. A number were mental health trainees including clinical

psychologists and psychotherapists (1, 4, 6, 7, 9, 11). However, it was unclear as to

whether these therapists had other clinical qualifications. Other intervention

approaches included: CBT (2, 8), counselling (10) and motivational interviewing (MI)

(5). One study included medical doctors who were on rotation training in dialectical

behavior therapy (DBT, 3).

Studies varied in the type of supervision reported and how supervision was

measured (e.g. group conditions of supervision or self-reported measures of

supervision). From the eleven included studies five studies evaluated the impact of

group supervision on observed competence (1, 3, 5, 7, 11). Of these five studies,

one study (7) described general group supervision whereas the other four studies

utilised a randomized control design (RCT) and compared different conditions of

supervision including: supervision as usual (SAU), supervision plus active learning

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

techniques (SUP+), bug in the eye (BITE), delayed video-based (DVB),

internetbased therapy with supervision (IBT-S) and MI.

Five studies used self-reported measures to explore frequency, effectiveness

and the perceived impact and importance of supervision on therapist observed

competence (2, 3, 6, 8, 10). One study explored the experience of supervision

through clinical interviews with participants (4).

The measurement of competence (perceived or observed) varied across the

studies. Some measured specific observed competence in relation to a clinical model

(CBT, DBT or MI) (1, 2, 3, 5, 8, 9, 11) and others explored therapist perceived

competence more generally (4, 6, 7, 10).

Five studies (1, 2, 8, 9, 11) measured observed competence using a specific

standardised scale for CBT, (CTS; Blackburn et al., 2001; CBTCOMP-YP; Lau &

Weisz, 2012). Both measures utilised supervisor ratings of therapists’ CBT

competence often completed on videoed sessions. DBT and MI competence were

examined using specific measures relevant to the model for two studies (3, 5).

Three studies relied on supervisee self-reported perceived competence (6, 7,

10). Two studies used self-evaluation scales (7, 10), whilst one used a survey to

examine supervisee competence specifically designed for the study (6). One study

used no specific measure of competence however, this was a theme presented in

the qualitative findings (4).

Quality of Studies Included

Each of the eleven studies were evaluated using the QATQS (n=9) or CASP

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

(n=2) depending on the predominant research design (Table 2). The quality of the

included quantitative studies varied with the QATQS scores ranging from Weak

(n=4), Moderate (n=4) to Strong (n=1; Table 3, Appendix B). The two studies rated

using CASP criteria (2013), were rated as 6 and 7 out of 10 (Table 4; Appendix C).

Both studies reported aims and methods well, however both studies failed to discuss

the researcher’s role within the research.

Five of the included studies (1, 3, 5, 9, 11) used an RCT design which under

the QATQS rating system is regarded as a strong methodological approach.

Although the studies used this design the sample sizes were relatively small, and

few commented on the confounders that were adjusted. It was unclear based on the

reported statistics of studies whether the power was sufficient to accurately detect

difference. Therefore, the inferences that could be drawn from these studies were

limited.

Selection bias within the samples was another area that varied across the

studies. Randomisation processes were well reported. However, the samples that

most studies drew from were of participants motivated to participate, self-selecting

into the study. This could have implications on how competence was perceived and

whether those who perceived themselves as less competent would not have chosen

to participate in the studies. This was not clear from the included studies.

18 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Table 2. Summary of articles included for analysis, ordered alphabetically by author

Reference and

Country

Design/

Method

Sample

Competence

Measures

Supervision

(e.g. type,

frequency,

model)

Analysis

Main Findings

Evaluation

QATQS/

CASP

category and

global score

Bearman,

Schneiderman

& Zoloth,

2017.

United States

Randomised

analogue

experimental

design to

control for

the effect of

supervision

on cognitive

restructuring

fidelity, CBT

expertise and

global CBT

competence.

Mental health

trainees enrolled

in clinical

psychology and

school-clinical

psychology

doctoral

programs,

n =40 (SAU

n=19, SUP+

n=21).

36 females and

4 males (M age

(years) = 25, SD

= 2.26)

Observed

competence

measured

using the

CBTCOMP-

YD (Lau &

Weisz, 2012)

Group

supervision

(SAU or

SUP+) – one

hour a week

for three

weeks

following a 3-

hour

workshop.

Paired sample

T-tests to

compare

effects of

training

pre/post to

randomisation.

Behavioural

rehearsal

coding, mixed

effects

repeated

measure

models for

each outcome

(e.g.

competence).

Both conditions

significantly

improved from pre

to post training

across cognitive

restructuring

fidelity, CBT

expertise and

global CBT

competence.

Participants

showed increased

knowledge of

CBT and global

competence in

the SUP+ group,

pre to post

supervision

workshop

(β = 1.04, t = 5.87

<p 0.001, d =

0.64).

The type of

supervision

received

differentially

impacted

therapist

behaviour e.g. the

Strengths

Examined

causal relation

between

supervision

and therapist

outcome.

Held client

complexity as

a constant to

systematically

assess

therapist

fidelity.

Use of a

control group.

Standardised

measure of

CBT

competence.

Limitations

Small sample,

motivated to

participate,

possible bias.

No follow-up

period.

A- Moderate

B- Strong

C- Strong

D- Moderate

E- Strong

F- Strong

Global

ratingStrong

19 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

inclusion of

roleplay, corrective

feedback

increased CBT

expertise and

global

competence.

Generalisabilit

y to training

and

supervision for

therapists.

Brosan,

Reynolds &

Moore, 2006.

United

Kingdom

Within

participants

correlational

design

Therapists

completing

postqualifying

training in CBT

(n =24).

17 females and

7 males (M age

(years) = 38, SD

6.5).

Observed

competence

measured

with

Cognitive

Therapy

Scale (CTS),

tapes rated

experienced

CBT

therapists.

Self-reported

frequency of

supervision

(weekly, once

every two

weeks, once

a month, less

than once a

month or not

at all).

Group

differences in

rated

competence

compared to

training,

experience,

and profession

and

supervision

frequency

using

MannWhitney

Test. Chi-

square and

fishers exact

test explored

categorical

associations,

Pearson

correlations in

whole sample.

Examined the

relationship of

therapist factors

to ratings of

cognitive therapy

measured using

the CTS. The only

factor significantly

related to

competence was

the level of

training (M = 20.5,

SD 4.6, U = 10.0,

p<0.001).

Number of years

of experience,

frequency of

supervision and

accreditation

unrelated to

ratings of

competence.

Strengths

Standardised

measure of CBT

competence.

Limitations

Small sample

size. Poor

response rate

(51%).

Correlational

design. Self-

reported

supervision

frequency, no

measure of

supervision. Self-

selected sample.

A- Weak

B- Weak

C- Weak

D- Weak

E- Strong

F- n/a

Global rating-

Weak

20 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

3 Carmel et al., Mixed- Trainee DBT theory Group BITE Independent Supports the use Strengths A- Moderate 2016. methods psychotherapist and skills supervision

samples of technological Use of BITE B- Strong

Randomised s (n=8, n = 4 exam, 50 or individual Mann-Whitney approaches like technology. C- Weak

United States to SAU, n = 4 items SAU. U test BITE in Randomisation D- Moderate Supervision BITE). completed at

compared supervision to process – E- Strong as usual the end of Supervision scores.

increase although F- Strong (SAU) or the DBT effectiveness competence in limitations

BITE with training measured Qualitative DBT. noted below Global rating- additional rotation. using the content with sample. Moderate

telephone Manchester analysis of Found those in

interviews. DBT case Clinical semi- the BITE group Limitations

formulation Supervision structured had significantly Small sample,

graded by a Scale – 26 interviews. higher scores on no

DBT (MCSS-26, case formulation demographic

therapist not Winstanley & (n=4, Mdn =3.6, U information blind to White, 2011) =

.00, p0.02, r provided. treatment and =0.83).

condition, supervisor Small sample

completed 5 feedback. Also reported for significance months into higher scores on testing.

training. DBT exam in

BITE condition. No measure of

Themes identified adherence to

from semi- DBT structured group

interviews: differences. Issues

with the

structure of BITE No control for

supervision, time other factors

management which may within

impact

supervision, supervision helpful process

of effectiveness.

21 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

feedback.

22 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Strengths

Johnston &

Milne, 2012.

United

Kingdom

Qualitative –

grounded theory

methodology

interviews

Trainee clinical

psychologists

(n= 7), all

female (M age

(years) = 26.71,

SD 2.06).

No specific

measure of

competence

used.

Interviews

explored

participants’

experiences

supervision

(models of

supervision

varied

dependent

on the

placement

included:

CBT,

systemic,

cognitive

analytic and

‘eclectic’

supervision.

Grounded

theory. Used

NVIVO (QSR,

2012) to

organise data.

The receipt of

supervision was

experienced

developmentally

involving the

progression of

competence and

awareness.

Core processes

were thought to

interact enabling

learning. The

authors discuss

the findings in the

context of a

model of CBT

supervision.

Findings

contribute to

the emergent

model of CBT

supervision.

Presents

experiences of

supervision.

Limitations

Supervisees

from one

course. No

specific

model of

supervision

tested,

trainees were

not selected

experience of

CBT

supervision.

CASP 6/10

23 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Martino et al.,

2016.

United States

Randomised

controlled

trial,

competencybased

supervision

Motivational

interviewing (MI)

was compared to

SAU.

MI clinicians (n=

66).

52 females, 14

males (M age

(years) = 41.3,

SD 13.2).

Observed

competence

and

adherence of

MI measured

though

coding of

video

sessions

using the

Independent

Tape Rater

Scale

(ITRS).

Supervision

conditions,

MIA: STEP,

clinicians’

videos were

rated, and

feedback

given using

the ITRS.

included

usual

practice;

checklist

Linear

regression

models were

completed for

outcomes

including

competence.

Demonstrated

that supervision

post training

increased MI

competence in

both MIA: STEP

and SAU

conditions. Those

in MIA: STEP

showed

significantly

higher increased

competence in MI

strategies

Strengths

Retention post

trial

Supervision as

usual group

Limitations

Biased group

of those

included in the

study -

motivated

A- Strong

B- Strong

C- Weak

D- Strong

E- Strong

F- Strong

Global rating-

Moderate

completed to

summarise

sessions.

compared to SAU

(M = 3.99 (SD

0.68) vs. M = 3.85

(0.66)).

24 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Strengths A-

Standardised B- measure of

C- D-

Nel, Pezzolesi

& Stott, 2012.

United

Kingdom

Mixed

methods-

retrospective

survey

design.

Trainee clinical

Psychologists

(n=357). 252

females, 105

males (M age

(years) = 41, SD

12).

No specific

measure of

competence

used.

Selfreported

perceived

competence

reported.

Self-reported

perceived

importance

supervision

on practice

measured

using a

survey

developed by

the authors.

First stage:

frequency

analysis of

responses

differences

compared

chisquare and

fisher’s exact.

Second stage:

qualitative

thematic

analysis from

two openended

questions

Live clinical

supervision was

rated as important

and useful by

93% significantly

associated with

years qualified.

Thematic analysis

highlighted

clinicians

perceived they

learned best

through

observation and

supervision to

develop

competency.

Discussed the

importance of the

supervisory

relationship for

learning to occur.

Strengths

Large sample

size

Limitations

Self-reported,

perceived

competence

and the

importance of

supervision.

Retrospective

responses.

CASP 7/10

25 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

26 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Strengths A-

Standardised B- measure of

C- D-

Ogren &

Jonsson, 2004

Sweden

Cohort -

Between

participants

correlational

design

Students part of

a five-year

academic

training for

psychology

(n=323).

Change in

therapeutic

skill

(perceived

competence)

measured

using the

Selfevaluation

scale (SES,

Olsson,

1996)

Skill

assessed

following

group

supervision.

Group

supervision

once a week

for 2 hours.

Factor

analyses,

Cronbach’s

alpha. T-tests

and one-way

ANOVA

comparing

group

differences.

Showed

significant

increases in skill

and positive

changes of skill

after supervision,

supervisees

perceiving self as

more skilful after

supervision (N=

76, M = 0.14 SD

0.39, p<0.001).

Group supervision

contributing to

greater skill

increase.

perceived

competence.

Factor analysis

of type of skill

important in

supervision.

Limitations

demographic

data of

sample.

Skill presumed

to represent

competence.

Self-reported

perceived skill

(competence)

increase.

psychometric

properties of

MSES

provided.

Weak

E- Weak

F- Weak

Global rating-

Weak

27 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Strengths A-

Standardised B- measure of

C- D-

Rakovshik &

McManus,

2013.

United

Kingdom

Mixed

method

survey

design of pre

and post

training CBT

competence

ratings.

Trainees (n=

73). 46 females,

27 males (M

age (years) =

39.59, SD 8.38).

Observed

competence

measured

using the

CTS.

Self-reported

the perceived

impact of

supervision

competence,

through

course impact

questionnaire

Paired t-tests CTS mean item

compared scores increased

trainee ratings. from 2.95 (SD =

CBT

competence.

Limitations Self-

reported.

Retrospective

design,

representative

population

queried.

CBT model of

supervision not

specified.

Strong

Moderate

Weak

E- Strong

F- n/a

Global rating-

Weak

0.64) to 3.83 (SD

= 0.69), with a

significant

difference (t72 =

8.31, p<0.001).

Supervision

perceived to have

the strongest

impact on

competence and

on trainees’

preparation for

practice.

Trainees rated

supervision

significantly more

highly compared

to clinical

instruction (M =

4.49 (SD 0.75):

vs. 3.74 (SD

0.69); t72 = 8.34,

p<0.001).

28 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Strengths A-

Standardised B- measure of

C- D-

Rakovshik et

al., 2016.

Russia and

Ukraine

Randomised

control trial.

Randomised

to IBT-CW,

IBT-S and DT

(who did not

receive the

training until

after all data

had been

collected).

Practicing

therapists

training in CBT

(n=61), 43

females, 18

males.

Observed

competence

measured

using the

CTS.

Skype

supervision

was given to

the IBT-S

group

consisting of

three 30minute

individual

monthly

sessions.

Linear random

effect models

considered

multiple

measurements

Sensitivity

analysis was

conducted.

CTS mean item

scores

significantly

increased over

time (baseline:

1.1 (95% CI = 0.6,

1.5, p<0.001) to

time 2: 1.2 (95%

CI = 0.8, 1.6,

p<0.001).

IBT-S showing

significantly

higher CBT

competence from

baseline ((M =

2.33 (SD 0.9))

post-training ((M

= 3.56 (SD 0.9)),

than IBT-CW (M =

2.87 (SD 1.0)) or

DT (M = 2.17 (SD

1.2)).

CBT competence

Design

Limitations

No follow up

period

Supervisory

bias in rating

competence

due to

nonblindness

of primary

rater.

Moderate

Strong

Weak

Moderate

E- Strong

F- n/a

Global rating-

Moderate

Steward,

Breland & Neil,

2001.

United States

Within

participants

correlational

design

Counselling

trainees (n=36).

32 females, 5

males (one

participant

Perceived

competence

self-reported

using

Evaluation of

Perceived

impact of

supervisor

style on

Pearson

correlations

and multiple

regression

The perception of

supervisor’s style

impacted

selfevaluation of

competence (r=

Strengths

Standardised

measures used.

A- Moderate

B- Moderate

C- Weak

D- Weak

E- Strong

29 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

missing from

overall n

presented in

paper).

Counsellor

Behaviours –

Long Form

(Bernard,

1981)

trainee

competence

measured

through the

Supervisory

Styles

Inventory

(SSI,

Friedlander &

Ward, 1984).

.59, p< 0.001). Limitations

Self-reported

Supported the Inconsistent

importance of the reporting of

support-challenge sample size

aspect of Multisupervision.

collinearity.

F- n/a

Global rating-

Weak

11 Weck et al., Randomised Therapists in Observed Supervision Latent growth Therapeutic Strengths A- Moderate 2016. control trial. psychotherapy competence

groups DVB curve models alliance and Standardised B- Strong

Randomised training (n=23). measured or BITE. In were specified therapeutic measure of C- Weak

Germany to DVB or 20 females, 3 using CTS. both for repeated competence were CBT D- Strong

BITE. males (M age conditions' ratings of stronger among competence. E- Strong (years) = 29.30, therapists therapeutic those who had

Randomised F- Strong SD 3.34). received six alliance and BITE supervision sample. Global rating-

supervisory competence. compared to DVB Moderate sessions for the CTS Limitations

during the ANCOVA’s on (Cohen’s d = Difference in

treatment of the group 0.39-0.66, therapeutic

the differences p=00.9). competence therapists’ between the and

patient. BITE and DVB therapeutic

conditions. alliance were

present at first

therapy

session

between

conditions.

Self-report of

therapeutic

30 CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Strengths A-

Standardised B- measure of

C- D-

alliance and

competence.

*Note: QATQS = Quality Assessment tool for Quantitative studies (Thomas et al., 2004): A= Selection Bias, B = Study Design, C =

Confounders, D = Blinding, E = Data Collection Method, F = Withdrawals and Dropouts. CASP = Critical Appraisal Skills Programme (CASP,

2013), CBTCOMP-YD = Cognitive Behavioural Therapy Competence Observational Measure of Performance with Youth Depression (Lau &

Weisz, 2012), SAU = Supervision as usual, SUP+ = Supervision plus active learning techniques, MIA: STEP = Motivational Interviewing

Assessment: Supervisory Tools for Enhancing Proficiency, BITE = Bug in the Eye, DVB = Delayed Video-Based, DT = delayed training controls,

IBT-CW = Internet based therapy with consultation worksheet, IBT-S = Internet based therapy with supervision.

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Main Findings and Implications

The following section presents the main findings of the review. The studies

are grouped to firstly consider the impact of supervision on supervisee competence

(observed vs. perceived) and to consider how supervision was measured.

Secondly the findings consider factors identified in the studies that were

perceived to contribute to effective supervision. Studies were grouped by the process

of feedback and the role of the supervisory relationship.

The impact of clinical supervision on supervisee competence.

Competence (observed vs. perceived).The outcome of competence was

measured using standardised measures of observed competence, self-report of

perceived competence or presented as a theme discussed within an interview. All

studies except one (2) showed a positive association between supervision and

increased therapist competence both perceived and observed (1, 3, 4, 5, 6, 7, 8, 9,

10, 11). One strongly rated study (1) reported effect sizes that were moderate; d

=0.64, showing increased competence for participants in the SUP+ condition. The

additional elements of scaffolding and experiential learning strategies included in the

SUP+ compared to the SAU condition appear to significantly improve competence

outcomes. The effect size was calculated for the purpose of the review for one study

(5) and showed a similar moderate effect, d = 0.49. It was however not possible to

calculate the effect size of other studies due to the statistics reported.

One study reported no positive association between supervision and

increased therapist competence evidencing the level of training to be the only factor

significantly related to increased competence (2). The quality of the study was weak

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

due to the small sample size and correlational design. Other factors such as

motivation of the supervisee and pre-existing competence in CBT were queried as

contributing to this finding however due to the study design could not be tested.

In the five studies that measured observed competence, the CTS or a

measure of CBT competence was used (1, 2, 8, 9, 11). A notable strength of these

studies was the use of an established standardised measure of CBT competence.

This potentially reduced the bias and increased reliability amongst assessing

competence of the supervisees and generalizability of the findings.

The five studies that used perceived competence utilised supervisee

selfreport measures (6, 7, 10), case formulation (3) or it was discussed as part of the

study interview (4). Self-report can lead to potential bias of data however; it has been

argued that evaluation of supervisee competence primarily occurs through verbal

discussion which would be based on perceived self-reported competence and

therefore may be a fairer reflection (Tweed et al., 2010).

How supervision was measured. A significant limitation of the included

studies was the variation in how they measured and reported on supervision. It was

not clear from all the included studies the frequency and intensity of most of the

supervision provided or the model of supervision used. This was not always a

primary focus of the study, for example one study (2) was interested in the

relationship of supervisee factors (e.g. experience, profession) and competence

ratings and examined the frequency of supervision and competence but found no

significant relationship.

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Six studies relied on self-reported information from the supervisee regarding

the experience of supervision (2, 3, 4, 6, 8, 10). These studies were interested in the

perceived importance of supervision and perceived impact of supervision on

competence. Three of the studies relied on feedback from the supervisee collected

through surveys specific to the study (2, 4, 6) or participant interviews (4).

Two studies used psychometric measures to examine elements of supervision

(3, 10). Study 3 used the MCSS-26 (Winstanley & White, 2011), a well validated

measure of the effectiveness of supervision across three domains which includes

formative development of clinical knowledge and skill of the supervisee. Study 10

assessed supervisory styles using the Supervisory Styles Inventory (SSI, Friedlander

& Ward, 1984) a validated measure where trainees rate various supervisory styles

including attractiveness and interpersonal sensitivity.

In the RCT designs the type of supervision used in the studies varied to

include supervision as usual vs. a specific supervision type (e.g. BITE, DVB). Studies

that examined the impact of a specific type of supervision compared to SAU reported

significantly improved CBT competence overall for both groups, with an increased

effect for the intervention groups (3, 11). A strength of the RCT design was the ability

to explore differences across supervision type, e.g. one study (11) reported stronger

therapeutic competence amongst supervisees who had received BITE supervision

compared with DVB.

What factors contribute to effective supervision in the development of

trainee therapists’ competence?

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

The process of feedback. A number of core processes particularly related to

feedback were identified in the studies as contributing to the development of

therapist competence during supervision (1, 3, 4, 6, 8, 11).

Three studies supported the positive impact of feedback on CBT competence

(1, 8, 3). A highly rated study (1) identified these core processes as active learning

strategies including: skill modeling, role play and corrective feedback which had

significant impact on participants’ global CBT competence. Across the three

supervision meetings participants had shown incremental improvements in their

global CBT competence if supervision had included these processes (1). Similarly,

study 6 reported direct feedback during supervision to have a positive impact on

CBT competence, yet the retrospective design of the study could impact the recall of

participants. A moderately rated study (11) evidenced increased CBT competence

for those in the BITE supervision intervention. The purpose of BITE supervision is to

enable immediate feedback to be given live to the supervisee whilst in a session.

Live supervision feedback is thought to be more useful than delayed supervisory

input (Rousmaniere & Frederickson, 2013). This supervision intervention was also

used in another moderately rated study which found increased DBT competence for

those in the BITE group compared to participants receiving SAU (3).

The Socratic approach to information exchange and feedback was noted as

an important factor within the qualitative study (4), in which the supervisee in

collaboration with the supervisor was able to ensure the learning process was

developmentally appropriate and motivating in developing the supervisee’s

competence. Interestingly, the participant’s level of confidence was associated with

the feedback received in supervision; which the authors had found to be of

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

importance in the development of competence (4). Similarly the qualitative findings

of study 6 reported the value of constructive feedback on supervisee performance.

However, these were two optional open-ended questions of the study and were not

completed by all participants therefore it is not possible to know if there was a bias to

those who valued feedback to respond to these questions.

Supervisory relationship. Three studies noted the role of the supervisory

relationship or alliance as an important factor in how supervisee competence

developed (4, 6, 10). Study 6 reported the importance participants placed on the

quality of the relationship with supervisors for learning to occur. However, these

findings were restricted to thematic analysis of two open-ended questions and

therefore findings were tentative.

Similarly, others have highlighted how a strong supervisory alliance enables

disclosure, mutuality and support with the relationship (Palomo, Beinart & Cooper,

2010). The importance of the supervisory alliance was a theme within study 4.

Supervisees shared how the perceived strength of their supervisory alliance would

impact how open and honest they were about their needs. The authors (4) discussed

how the “emotional climate engendered within the supervisory alliance had a strong

impact on what was received and reflected upon” (p.14) which contributed to their

overall development and competence.

Study 10 noted a correlation between perceived attractiveness of the

supervisor (attractiveness defined as friendly, flexible, supportive, open, positive, and

warm) with supervisee accuracy of self-evaluation. This was a poorly rated study

particularly due to potential multi-collinearity between variables.

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Discussion

The purpose of this review was to evaluate the literature that reported on the

impact of clinical supervision on supervisee competence, and the factors that

contribute to effective supervision in this process. A comprehensive search identified

eleven studies which met the inclusion criteria. Consistent with previous research the

included studies suggest an overall positive association between supervision and

supervisee perceived and observed competence. Although both feedback and the

supervisory relationship were factors found to contribute to the process of

competence development within supervision (Heckman-Stone, 2004; Kilminster &

Jolly, 2000); the process of feedback was better evidenced in the current review.

Both these main findings are tentative due to methodological limitations and

complexities identified within this area of research which will be discussed.

The included studies varied in the measures assessing competence and the

type of supervision which made it difficult to draw conclusive comparisons across the

studies. The findings however provided some evidence of the positive impact of

clinical supervision on supervisee competence. Of particular interest in this review

was the impact of increased supervisee competence in those groups where an

additional element was included within the supervision condition (e.g. BITE, DVB,

and SUP+).

The use of BITE supervision for example, increased overall DBT (3) and CBT

(11) competence in the supervisees. BITE has been argued to be advantageous to

supervisees learning in the moment (Rousmaniere & Frederickson, 2013).

Methodological limitations in these studies meant the generalisability of these

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

findings is limited. The sample size of study 3 was particularly small which may have

led to chance findings. Study 11 showed baseline differences between supervisee

CBT competences to be present at the first therapy session and due to the small

sample size the study was unable to explore this further in the analysis.

Study 1 found significant differences between therapists’ CBT and global

competence, pre and post training, in the two supervision groups however this was

based on a small sample of motivated participants and there was no follow-up

period. This was a general theme across the studies and no longitudinal studies

were included within the review or follow-up periods which could inform the

longerterm impact of supervisory processes on competence development. As many

of the studies did not explicitly report on confounders, it was unclear if supervisee

factors such as previous experience and supervisor competence impacted on the

supervision processes.

The review evidenced feedback as a potential contributory factor within

supervision on the development of supervisee competence, however further

research is needed to establish the role and type of feedback that is key. Similarly

the supervisory relationship was identified as an important factor. HeckmanStone’s

(2004) review of existing literature indicated feedback and evaluation to be effective

in producing change in supervisees, facilitated through a supportive supervisory

relationship which was a consistent finding within the present review.

The current review supports and extends the work of Alfonsson and

colleagues (2018) who explored the effects of supervision on CBT competence. The

present review included a broader inclusion criterion of therapeutic approach and no

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

restrictions on how competence was measured. Three of the papers (3, 9, 11) were

included in the current review. However two papers Bambling (2006), and Tanner,

Gray & Haaga (2012) were excluded. Bambling (2006) was excluded from the

current review as the focus of competence development was discussed in relation to

treatment outcome and Tanner et al., (2012) focused on the effects of co-therapy on

trainee effectiveness measured by symptom distress in patients.

Strengths and Limitations

One of the main strengths of conducting a systematic review is the

methodology used to identify, select and review the relevant literature, in order to

minimise bias. Specific search terms were carefully selected to address the research

questions, although the search terms were amended in an iterative process, two of

the included papers were identified through hand-searches (3, 9). Neither paper

referenced competence within the abstract, title or keywords. Both papers included

the term “training” however when this was added to the search terms the number of

studies increased considerably and through discussion with a specialist librarian it

was deemed appropriate to omit the term. The present review included no grey

literature due to time constraints which may have impacted publication bias of the

included studies, future reviews could be improved further by inclusion of

unpublished literature.

A further strength of the review was the inclusion of both perceived and

observed competence. For clarity, within the current review, distinctions were made

between observed competence if the competence had been measured using a

standardised measure and/or approach. The inclusion of perceived competence

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

meant the review was not limited to therapy models that have used standardised

measures of competence and included self-report of supervisees, as this is common

practice in clinical training and practice (Tweed et al., 2010). Many of the studies

included examined observed competence in relation to a specific model or

intervention. Some therapeutic approaches include structured competence scales

e.g. CBT, CAT, systemic practice. Interestingly studies included in the review only

used structured CBT measures and no other model specific measure was used,

which is a limitation of this review.

The review took a broad approach to exploring the impact of supervision on

supervisee competence extending previous reviews conducted (Alfonsson, 2018).

However, similar to the review conducted by Alfonsson et al. (2018) methodological

limitations meant the generalisability of the findings was limited. The quality of the

studies varied. The QATQS measure used to assess quantitative studies favoured

RCTs which meant a number of studies were scored lower due to the design but also

those rated higher due to an RCT may be misleading to the overall quality of the

study.

The process of developing competence is complex and is likely to be impacted by

a number of supervisory and individual factors that were not explored in the current

review. The studies included in this review were unable to provide the mechanisms

of change related to competence development which would be beneficial to explore

further. Factors related to supervision styles e.g. frequency, type, intensity were also

not always provided and therefore comparisons across studies was not possible.

Criticisms have been made around the methods of measurement of supervisee

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

competence, the bias that may exist within supervisory relationships and how this

would impact the way competence is measured (Tweed, et al., 2010).

Implications for Future Research and Practice

Although it is accepted that supervision is an important aspect of clinical

practice, in line with the conclusions of Alfonsson et al. (2018) the present review

suggests a more empirical approach to understanding the components and possible

mechanisms that contribute to improved clinical competence for supervisees is

needed. Feedback for example was highlighted as a contributory factor within this

review; however further research to understand this relationship is needed e.g.

clarity on how feedback is provided within supervision.

The majority of studies measured CBT competence which could reflect the

increased interest and funding for CBT trials with the development of IAPT and the

need for outcome measures both for the client and clinician. Sharpless & Barber

(2009) highlight the challenges for other disciplines such as Clinical Psychology,

which is characterised by multiple competing paradigms. They argued the way some

competence measures are used may be a limitation when considering the broader

competence of a clinician.

One qualitative study was included within the current review and presented some

of the supervisee’s perception of supervision where competence was discussed (4).

However, this was not a specific focus of the research and further exploration

between competence development and the supervisory process could be explored,

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

as supported by Wilson et al.’s review (2016). In addition, it would be interesting to

untangle further the potential barriers of using competence scales in supervision and

whether they are helpful as an adjunct to the more informal evaluative conversations

that take place (Tweed et al., 2010; Butler et al., 2018).

Although the review considered how supervision was measured it did not

explicitly focus on the competence of the supervisor to deliver supervision. In most

studies the role of the supervisor was discussed yet not explored further. Falender &

Shafranske (2004), highlighted this as an area of professional practice which has

largely been neglected although there have been some recent developments such

as the UCL competence framework for supervision. This is an important area for

future research as it potentially impacts on service development (i.e. accessibility of

supervisors and their training and continued professional development) as well as

patient outcomes (UCL, 2019).

Conclusion

The importance of clinical supervision is widely accepted and with a shift

towards competence-based practice there is a need to understand the relationship

between supervision and supervisee competence development. The current review

systematically explored the relationship between clinical supervision and supervisee

perceived and/or observed competence in clinical practice. The review extended a

previous review conducted by Alfonsson et al. (2018) by broadening the inclusion of

the therapeutic approach and focusing specifically on the role of supervision. The

current review has demonstrated some evidence of a positive relationship between

supervision and supervisee competence however the review raises a number of

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

limitations with the studies and questions how best to measure this relationship in

future studies.

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Appendices  
Appendix A: Example search strategies (PsycInfo and ASSIA)  

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Appendix B: EPHPP full table

Appendix C: CASP full table

Appendix D: Journal guidelines (The Clinical Supervisor)

50  
CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE   
  
 
Appendix A  
Example search strategies  
PsycInfo  
1  Exp Therapist Trainee/  
2  (Trainee* adj2 
therap*).ti,ab.   
3 (trainee* adj2 Psycholog*).ti,ab.   
4 (Trainee practitioner* or Psychology practitioner*).ti,ab.   
5 1 or 2 or 3 or 4   
6 exp Professional Supervision/   
7 (Supervis* or "Clinical Supervis*").ti,ab.   
8 6 or 7   
9 exp PROFESSIONAL COMPETENCE/   
10 (competence* or experience* or perception*).ti,ab.   
11 9 or 10   
12 5 and 8 and 11  
  
ASSIA  
MAINSUBJECT.EXACT.EXPLODE("Therapists") or ("trainee NEAR/2 Therap*") or ("trainee  
NEAR/2 Psycholog*") or ("trainee NEAR/2 practitioner*") or ("psychology practitioner")   
  
MAINSUBJECT.EXACT("Professional competence") OR  
MAINSUBJECT.EXACT("Perceived competence") OR ("competence*")   
  
MAINSUBJECT.EXACT("Supervision") OR ("professional supervision") OR ("clinical 
supervision")   
  
(MAINSUBJECT.EXACT.EXPLODE("Therapists") OR ("trainee NEAR/2 Therap*") OR ("trainee  

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

NEAR/2 Psycholog*") OR ("trainee NEAR/2 practitioner*") OR ("psychology practitioner") .noft)

AND (MAINSUBJECT.EXACT("Professional competence") OR

MAINSUBJECT.EXACT("Perceived competence") OR ("competence*") OR ("experience*") OR

("perception*") .noft) AND (MAINSUBJECT.EXACT("Supervision") OR ("professional

supervision") OR ("clinical supervision") .noft)

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Appendix B

Table 3. EPHPP quality rating full

No.

Reference

A-

Selection

Bias

B-

Study

Design

C- Confounders

D- Blinding

E-

Data

Collection

Method

F- Withdrawals and

dropouts

Overall

rating

Bearman,

Schneiderman

& Zoloth,

2017

Strong

Brosan,

Reynolds &

Moore, 2006

n/a

Weak

Carmel et al.,

2016

Moderate

Martino et al.,

2016

Moderate

Ogren

&Jonsson,

2004

n/a

Weak

Rakovshik &

McManus,

2013

n/a

Weak

Rakovshik et

al., 2016

n/a

Moderate

Steward,

Breland &

Neil, 2001

n/a

Weak

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Weck et al.,

2016

Moderate

Note: 1 = Strong, 2= Moderate, 3 = Weak

Appendix C

Table 4. CASP Overall table

No.

Reference

Validity

Aims

Validity

Methodology

Validity

Design

Validity

Recruitment

Validity

Addresses

Research

Questions

Validity

Researcher

role

Results

Ethical

issues

considered

Results

Rigorous

Results

Clear

statement

findings

Results

Valuable

Overall

rating

Johnston

& Milne,

2012

CT –

somewhat

6/10

Nel,

Pezzolesi

& Stott,

2012

7/10

Note: Y= Yes, N= No, CT = Cannot tell

CLINICAL SUPERVISION AND SUPERVISEE COMPETENCE

Appendix D

Copy of journal guidelines for authors for the nominated journal, The Clinical

Supervisor

Preparing Your Paper

Structure

Your paper should be compiled in the following order: title page; abstract; keywords;

main text introduction, materials and methods, results, discussion;

acknowledgments; declaration of interest statement; references; appendices (as

appropriate); table(s) with caption(s) (on individual pages); figures; figure captions

(as a list).

Word Limits

Please include a word count for your paper.

A typical paper for this journal should be no more than 30 pages, inclusive of the

abstract, tables, references, figure captions.

Style Guidelines

Please refer to these quick style guidelines when preparing your paper, rather than

any published articles or a sample copy.

Please use American spelling style consistently throughout your manuscript.

Please use double quotation marks, except where “a quotation is ‘within’ a

quotation”. Please note that long quotations should be indented without quotation

marks.

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Formatting and Templates  
Papers may be submitted in Word format. Figures should be saved separately from 
the text. To assist you in preparing your paper, we provide formatting template(s).  
Word templates are available for this journal. Please save the template to your hard 
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provides a range of editing services. Choose from options such as English Language 
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Translation, and Artwork Preparation. For more information, including pricing, visit 
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Checklist: What to Include  

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Author details. All authors of a manuscript should include their full name and 
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Disclosure statement. This is to acknowledge any financial interest or benefit that 
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Running Head: STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

SCHOOL OF PSYCHOLOGY

DOCTORATE IN CLINICAL PSYCHOLOGY

EMPIRICAL PAPER

Student and Supervisor Experiences of the Systemic Practice Scale (SPS)

Measure: A Discourse Analysis

Trainee Name: Dr Claire Hannah Parker

Primary Research Supervisor: Dr Janet Smithson

Senior Lecturer in Psychology, University of

Exeter

Secondary Research Supervisor: Dr Jenny Limond

Research Co-Director for Doctorate of Clinical

Psychology, University of Exeter; Consultant

Clinical Neuropsychologist

Target Journal: Journal of Family Therapy

Word Count: 7994

Submitted in partial fulfilment of requirements for the Doctorate Degree in

Clinical Psychology, University of Exeter

Abstract

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

There has been a recent emphasis on the assessment of competence in clinical

training courses to improve evidence-based practice and outcomes for clients. The

systemic practice scale (SPS) was developed as a structured way to evaluate

systemic practice. There is however little research on the impact and experience of

competence measures particularly within the context of systemic practice.

Focus groups conducted with students and supervisors from systemic family

practice (SFP) programmes explored their views of the SPS as an appropriate

measure of systemic competence. Three dominant discourses were identified:

feedback as valuable, measuring competence, and being systemic. These

discourses recognised the usefulness of a scale to measure systemic competence

but also the tensions that this raised for both students and supervisors.

Clinical and practice implications for the use of the SPS in assessing systemic

competence need to be considered in line with the values of systemic practice,

maintaining reflexivity and collaboration between the student and supervisor in

order for the feedback to have a meaningful impact on student development.

Key words: Competence, Discourse analysis, Supervision, Systemic Practice

Introduction

Competence Based Practice and the Systemic Context

Competence-based practice has become a focus of evaluation for trainees

across clinical training courses to ensure safe and effective practice (Gallichan &

Mitchell, 2008; Roth & Pilling, 2007; Sutherland, Fine & Ashbourne, 2012).

Competence in the context of psychotherapy has been defined as “a standardised

requirement for an individual to perform a specific job” (Stratton et al., 2011, p.123).

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Gallichan & Mitchell (2008) suggest competence is “a multi-faceted construct: it is

more than how someone thinks, but it is also more than what someone does” (p.18).

The formal purpose of assessing an individual’s competence is to provide helpful,

meaningful and constructive feedback for the individual to reflect on their clinical

skills, highlighting possible areas of development (O’Donovan, 2015).

Assessment of a trainee’s competence is argued to be a developmental and

contextually based process extending from training into qualified practice. This

process is dependent on supervision, formative and summative assessment and the

therapy modality (Epstein & Hundert, 2002; Tweed, Graber & Wang, 2010).

Selfreport during supervision is the predominant method of assessing clinical

competence (Scaife, 2003; Tweed et al, 2010). Within supervisory interactions

trainees develop knowledge, understanding and competence (Bernard & Goodyear,

2014; Burnham, 2018; Scaife, 2003). In addition supervision can alleviate signs of

distress, burnout and self-criticism which are factors thought to impact trainee

competence (Ladany, Mori & Mehr, 2013; Wilson, Davies & Weatherhead, 2016).

Within a systemic context Anderson and Swim (1995) suggest learning in

supervision is interactional, where new knowledge and competence evolves through

dialogue and relational reflexivity. Some have suggested competence-based training

challenges this systemic paradigm of interaction and locates competence solely

within the individual irrespective of the context (Simon, 2010; Sutherland et al.,

2012). Simon (2010) discusses the challenges systemic supervisors have working

within training courses that are “dominated by inflexible professional narratives”

(p.308) that may not fit within a culture where micro-measurement of clinical practice

has become the norm (Butler et al., 2018; Tweed et al, 2010). Sutherland et al.

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

(2012) argued from a social constructionist perspective “what is ‘noticed’ will depend

in part on the observer’s theoretical and philosophical commitments” (p.3). Some

have questioned whether the use of a specific systemic competence scale would

capture the contextual layers of systemic practice (Moran, 2017), providing “a limiting

or reductionist view” (Butler et al., 2018, p.3).

The introduction of the improving access to psychological therapies (IAPT)

programme in 2008 saw the establishment of competence frameworks for the

practice of effective evidence based psychological therapies (Clinical Outcomes in

Routine Evaluation, CORE, 2017). A number of psychometric scales exist to assess

competence, such as the widely used cognitive therapy scale (CTS-R, Blackburn et

al., 2001), however these initiatives came primarily from the cognitive behaviour

therapy (CBT) models and within the field of systemic therapy up until recently there

had not been an equivalent.

The systemic practice scale (SPS

) was developed in response to current

changes in the delivery of mental health services for child and young person’s IAPT

(CYP-IAPT) and the lack of measures to assess systemic competence (Butler et al.,

2018). It is used within CYP-IAPT systemic family practice (SFP) courses across the

UK, providing a structured assessment of systemic skills that can be used in

supervision or as a training tool (Butler et al., 2018, Appendix A). The measure

consists of twelve items to assess supervisees’ competence across a number of

domains such as, interpersonal effectiveness, collaboration and use of questioning.

The SPS was initially titled the Systemic Family Practice – Systemic Competency Scale (SFP-SCS)

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

A small-scale study demonstrated high internal reliability (Intraclass Correlation

Coefficient (ICC) 0.94 ((CI: 95% 0.89-0.97) F (22, 297) = 20.36, p<0.001)) and

reported the measure held face validity based on use within CYP-IAPT training

courses (Butler et al., 2018). The study included a thematic analysis of 23

supervisors’ experiences of using the scale. Supervisors reported the SPS was a

helpful way to give feedback to students but recognised this approach required

flexibility in providing “feedback beyond the scale” (Butler et al., 2018, p.16).

There is limited research on the lived experience of clinical trainees training,

particularly in the context of systemic practice (Nel, 2006). Nel (2006) provided a

qualitative account of the experiences of training as a family therapist and found

students reported training as “overwhelming and de-skilling, but that it nevertheless

provoked a re-evaluation of some of their established personal, relational and

professional identities” (p. 307).

Discourse Analysis and Systemic Practice

Discourse analysis (DA) is concerned with how the use of language is

implicated in the construction of versions of events (Willig, 2014). DA emphasises

how social reality is achieved through the construction and function of language as a

tool of social action (Georgaca & Avdi, 2012). DA prioritises reflexive ideology and

practice (Avdi, 2005). Both DA and systemic approaches draw from a shared

theoretical basis in social constructionism (Tseliou & Borcsa, 2018), whereby reality

and meaning “are systematically constructed and maintained through systems of

meaning and through social practices” (Georgaca & Avdi, 2012, p. 2). Social

constructionism influences in systemic practice have emphasised the “role of

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

language and multiple layers of context” (Tickle & Rennoldson, 2016, p.127). In

systemic practice it is acknowledged “the therapist’s ways of viewing the world, our

talk and ways of acting powerfully affect the therapeutic conversation and the client”

(Hedges, 2005, p.26). Systemic approaches are driven by the context and systems

of interactions (Bronfenbrenner, 1979; Burck, 2005) which is acknowledged in DA

(Gee, 2014; Georgaca & Avdi, 2012).

Through a DA framework attention is given to the effects of the choice of

words used to express or describe something (Willig, 2014). Georgaca & Avdi

(2012) consider the impact of subject positions within DA and how these influence

the function of talk but also the content (Davies & Harre, 1990), through asking “who

speaks? In whose name do they speak? Who do they address? Who do they speak

for?” (Georgaca & Avdi, 2012, p.155). Systemic practice draws on the concept of

subjectivity and how discourses shape relationships and interactions. Burck (2005)

highlights how “the notion of ‘discursive practices’ addresses questions of agency

through critically examining ways individuals position themselves and are positioned

through language” (p.251).

Discourses can be identifiable and produced through pre-conceived

institutional practices such as frames of reference e.g. roles and expectations in

clinical settings. DA enables consideration of the wider contextual factors that may

influence clinical understanding (Georgaca & Avdi, 2012; Potter & Wiggins, 2007).

Roy-Chowdhury’s (2006) work examining systemic therapy through DA interestingly

orientates the analysis towards positioning whilst “maintaining an awareness of the

ways in which speech constitutes and represents the negotiation of identities,

psychological states, power relations and social and institutional structures” (p.157).

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

The present study is grounded within DA and systemic theory through a shared

theoretical social constructionist approach.

Aims and Research Questions

Assessing the competence of practitioners delivering systemic therapy

remains important in maintaining validity of treatment for clients, demonstrating

effectiveness of training and assisting therapists in their clinical development. There

is little research on the impact and experience of competence measures particularly

within the context of SFP. The current study aims to expand this area of research to

gather the perspectives of supervisors’ and students’ experiences using the SPS.

The present study aimed to explore student and supervisor experiences of the

SPS using a DA framework. The following research questions guided the analysis:

1. Do systemic students and supervisors view the SPS as an appropriate

way of assessing systemic competence?

2. How are discourses regarding systemic competence (in reference to the

SPS) constructed within the context of systemic training?

Methodology

Design

A qualitative focus group design was used and data were analysed using DA

methodology.

Participants

Recruitment was purposive, students and supervisors from four SFP

programmes across the UK were invited to participate (Table 1). A course

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

requirement from all sites was the completion of the SPS at three time points across

the academic year. Three video recordings of clinical work with families/couples were

submitted by students, which are subsequently rated by supervisors using the SPS.

The process of receiving feedback from the SPS varied; in addition to individual

written feedback, some received verbal group feedback.

Five focus groups were held across two sites; three student groups and two

supervisor groups. Supervisors and students participated in separate focus groups.

All participants were asked to complete a demographic questionnaire, derived

specifically for this study (Appendix B). A semi-structured topic guide (Appendix C)

guided group discussions, facilitated by the researcher in order to actively encourage

group members to contribute to group discussions (Wilkinson 2008). The topic guide

was based on the reflective section of the SPS developed by a training course within

the SW of England and through discussions with SFP practitioners. A pilot focus

group was conducted with five SFP students to check the structure and clarity of

questions asked. The topic guide was slightly amended when interviewing the

supervisors (See Appendix C).

All groups were audio-recorded and transcribed verbatim using Jefferson

notation (Jefferson, 2004; Appendix D).

Table 1

Summary of Participants Included within each Focus Group

Group

Date

Participant

profile

Number of

participants

Age (years)

Mean (SD)

Range

Gender

Length in

current role

(years)

Range

September

2018

Student

41.6 (10.7)

31-56

5 Women

1-4

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

October

2018

Supervisor

54.7 (6.7)

45-60

1 Man

2 Women

5-29

November

2018

Student

42.4 (7.8)

28-52

1 Man

6 Women

4-12

November

2018

Supervisor

53.3 (8.9)

42-62

1 Man

3 Women

1-5

November

2018

Student

38.5 (2.7)

34-41

1 Man

3 Women

2-4

Totals:

45.0 (10.0)

28-62

4 Men

19 Women

1-29

*Note: SD, Standard Deviation

Procedure and Ethical Considerations

Ethical approval was granted from the School of Psychology Research Ethics

Committee at the University of Exeter (Appendix E).

The study was discussed with course leads across the sites of recruitment for

approval to disseminate information to students and supervisors. The information

sheet and consent forms (Appendices F-H) were distributed through the

administration team, inviting participants to take part in the focus group. Groups were

scheduled to ensure students had received feedback from at least two SPS.

Informed consent was obtained from all participants prior to conducting the

group and all participants were informed of their right to withdraw from the study.

Confidentiality and anonymity are issues raised when conducting focus groups due

to the nature of group participation (Smithson, 2018). Participants were made aware

within the information sheet and again at the beginning of each group, of the

limitations of confidentiality in a group setting and the importance of respecting group

members’ views.

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Data Analysis

Data collected through focus groups were analysed using DA following Potter

and Wiggin’s guide to DA (Potter & Wiggins, 2007;Appendix I) and informed by

Georgaca and Avdi’s five levels of DA (Georgaca & Avdi, 2012; Appendix J).

Focus groups are advantageous in enabling pre-existing groups of individuals

with shared characteristics to discuss a topic of interest (Wilkinson, 2008). DA

enables the exploration of group talk and the use of rhetorical strategies to achieve

particular outcomes (Duggleby, 2005; Potter & Wetherell, 1987). There are several

explicit and implicit factors thought to affect group dynamics including power,

positioning of role, hierarchies and experts as well as emerging consensus

(Smithson, 2018).

Due to word count limitations, the analysis focused on how group participants

used rhetorical strategies within group interaction to position themselves and others

in the group (Georgaca & Avdi, 2012; Potter & Wiggins, 2007). The analysis focused

on the group talk discourses regarding the SPS within the context of their systemic

practice (Burck, 2005; Roy-Chowdhury, 2010).

The process of analysis involved an initial submersion within the data, reading

and re-reading the transcripts. Transcripts were coded within NVIVO (QSR, 2012)

which enabled a systematic approach to the analyses and the identification and

interpretation of patterns in the discourse (Potter & Wetherell, 1987). Key discourses

associated with the research questions were identified and extracts are presented in

the findings to illustrate these and the discursive practices used (Jorgensen &

Phillips, 2002). Georgaca and Avdi (2012) propose five levels at which DA can occur

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

(Appendix J, Table 2). These levels were utilised as a guide within the current

analysis enabling a flexible approach to the iterative process. Although all levels

were considered, the analysis focused on level 2 (the function of language within the

groups) and level 3 (how language was used to position group members).

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Quality Criteria

Evaluative criteria consistent with DA’s epistemological approach were

considered in order to appraise the quality of the research (Georgaca & Avdi, 2012).

They suggest five useful evaluative criteria: internal coherence, to ensure there is

consistency in the data presented, forming a coherent narrative; rigour, through

attention to inconsistency. Data needs to be transparent and situated ensuring the

stages of research are clear and the extracts are grounded within the analysis

enabling the reader to draw judgements on both the quality and findings themselves.

Reflexivity, in the process, by the researcher attending to their role and bias and

finally the usefulness of the data and wider implications. A reflexive diary was kept

throughout recruitment and analysis to maintain transparency of the process and my

role.

To ensure fidelity to the DA approach extracts of the data were presented at a

DA group where group analysis and discussion took place. In addition, my

supervisor, who was a discourse analyst, reviewed extracts. These processes aimed

to mitigate issues raised previously on the reflexivity of the researcher position and

gain further perspectives on the work. This allowed for critical appraisal and

evaluation of the work in line with the DA methodological approach.

Results

Five focus groups were conducted across two sites. Groups consisted of

either students currently enrolled on the SFP training or supervisors of those

courses. The length of groups ranged from 34 to 52 minutes with the average group

lasting 42 minutes.

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

The majority of participants were women with varied lengths of experience

within their current role. All students were experienced practitioners with varied

backgrounds and current roles, including clinical psychologists, social workers,

primary mental health workers and systemic family practitioners.

Analysis

The following section discusses 11 extracts selected from across the five

focus groups. The extracts are organised by three dominant discourses, feedback as

valuable, measuring competence and being systemic. For each discourse where

possible both the student and supervisor perspective are presented. Brackets after

words indicate line references in extracts. In line with the DA approach, extended

extracts are presented to enable the reader to judge the coherence and plausibility of

the analysis which is discussed alongside relevant literature (Georgaca & Avdi, 2012;

Potter & Wiggins, 2007).

Feedback as valuable

The implicit purpose of assessing an individual’s competence is to provide

feedback that enables individuals to reflect on their practice (O’Donovan, 2015). In

all student groups the process of receiving feedback and the value of this was

reflected on. The following extracts present the student and supervisor discourse of

feedback as valuable. Extract one comes from the beginning of focus group (FG)

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

one. The students were asked an open-ended question by the researcher to share

their experiences of receiving feedback from the SPS.

Extract 1: FG1 Students

Sarah

: (…5…) ((group laugh)) ˚Um I think I was saying before that um it’s a bit

scary receiving feedback because we know it’s going to be really valuable but the

fact someone has sat and watched you for an hour and has made all these

comments and might you might have thought you’ve done something well and they

might have thought it wasn’t ↑ quite as good as what you thought, that can be a bit

scary, because it’s personal isn’t it? It’s not anonymous like the rest of our work˚

R3: Yeah so they can physically [yeah see you in your tape

((All nod)) Sarah: yeah]

Victoria: It does kind of seem like well it does to me the most valuable (…)

feedback that we get rather than you know the feedback from essays.

That that feedback was what I was really really waiting for and really

wanting to find out about, wanting to sort of even though even though

(…) dreading it wanting to get those observations. Spend that time

reflecting on yourself which is really so important

A dominant discourse evidenced within extract one is how students viewed

the feedback as “valuable”. Victoria’s repetitive use of the word “really” (17) functions

to reiterate the importance of the feedback. The students switch between the use of

‘I’ to ‘we’ as a potential way of maintaining solidarity and collaboration of the group

All names and identifying features have been changed and pseudonyms used to protect anonymity

of participants and places. 3 Note: ‘R’ refers to the researcher

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

position on receiving feedback (Donohue & Diez. 1985).

Sarah’s use of the wording “valuable, but...” (8) indicates that there is an

assumption or training norm that the feedback is valuable however the use of “but”

suggests some discomfort with the idea that the measure is unquestionably valuable.

Similarly the pause in line 15 by Victoria could reflect this uncertainty.

The group also refer to the feedback as “scary” (8) and “dreading it” (19). The

discomfort of receiving feedback is not uncommon, sometimes leaving trainees

feeling de-skilled (Nel, 2006). Although the students do not refer to this, the extract

highlights the exposing nature of being observed and judged and the uncertainty this

creates, highlighted by the question asked by Sarah (13).

As the discussion progresses some group differences arise in how the

measure is viewed as “valuable”. Extract two highlights two contrasting views, this

discussion comes after the students had been asked if they felt the measure

impacted their competence in systemic practice.

Extract 2: FG1 Students

Harriet: I think it does when I’ve used it it definitely highlights areas I think

really need to focus on developing my skills in so it’s that bit of um (…)

good at helping you to develop what you need to develop however

hard it is to sort of (…) your really not good at that but it’s a nudge isn’t

it that if you want to be good at your job this is ˚an invitation to learn

how to get better at it˚

Laura: but I see it completely differently I see it as a paper exercise that you

have to do as part of the course [R: yep] ˚and actually˚ (…) I use my

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

supervision thinking about what I need to improve (…) so I think for

m:e if they really want it to be (.) collaborative experience then maybe

they should bring it into supervision that we have at university a bit

more so that then if we were having supervision and they watch a bit of

our tape they could say well (…) if you were thinking about x section on

the scale where would you scale yourself and why would you do that

so that they could link it into supervision because it does j:ust feel like

it’s a paper exercise tagged on it doesn’t feel very collaborative with the

other kind of stuff we do around looking at how we are getting on with

our practice in supervision

Sarah: ˚I think um I was just thinking about whether I took it back into practice

and˚ ↑actually I think that I really agree it would be really helpful to

have it referenced more in supervision both here at the uni and in the

workplace

Harriet begins by re-emphasising the value in the feedback received in

developing systemic skills. She uses a qualifier “however” (120) to indicate the

imagined anxiety of being told what you’re “not good at”, reframing it as a “nudge”

(121). She poses this in a question to the group “isn’t it” (121), possibly seeking

reassurance and approval in her view point. Nel (2006), found participants were

presented with dilemmas throughout their systemic training to re-evaluate their

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

professional identities through the new knowledge and skills of the course. The

“nudge” Harriet discusses could be a reference to this re-evaluation of identity as all

the students are already qualified practitioners.

In contrast Laura offers an opposing view to the group, presenting the measure as

a “paper exercise” (124), locating it as part of the context of the course that is not

“collaborative” (127 and 133). Laura states how “actually I use my supervision…”

(125) interrupting the discourse of the measure as valuable in guiding the process of

development and inviting the supervision context as a place to consider

competence. Laura invites a different perspective of the use of the measure in

collaboration with the supervisors, rather than being “tagged on” (133).

Later within the same focus group this perspective of collaboration of the

supervisor and student perspective is acknowledged further, “I kind of feel it’s a very

sort of undervalued resource in a way that I can really see you saying you had a

conversation with your supervisor about your scores and how you could change it if

you had the time to do that would be such a valuable kind of resource” (186-188).

This acknowledges the importance of the supervisory relationship to support student

development through feedback and discussion (Anderson & Swim, 1995; Sutherland

et al., 2012).

Extract 3 shares part of a discussion between the supervisors about their

relationship in the process of feedback. The extract follows a discussion regarding

the marking process of the measure.

Extract 3: FG2 Supervisors

306 Stuart: the feedback so we don’t have the feedback

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

R: the loop

307

Stuart: so we’re saying that the the SPS might be effective and might be

308

useful scale but we are not necessarily using it as well as we could do

309

↑but we’ve got limited resources though ((laughs)) lets lets be blunt

310

(inaudible)

311

Abi: well you know people don’t bring clips you know

312

Stuart: [yeah

313

Ceri: but more than that they should be bringing it to their clinical supervision

314

their workplace supervision [Abi: yeah] and saying look I’ve just scored

315

really high

316

Stuart: Yeah yeah]

317

Ceri: on this and this I need to work on this and this

318

Here the supervisors discuss how the feedback from the SPS “might be

319

effective and might be useful” (308) alongside feedback within supervision. The use

320

of the language “let’s be blunt” (310) positions Stuart as pragmatic and

321

solutionfocused, whilst communicating the challenges of the course context and the

322

impact of “limited resources” (309-310). The extract introduces the wider

323

expectations of the course and the workplace (Simon, 2010). The emphasis on “well”

324

indicates a frustration of what then Ceri states as what the students “should” be

325

using the feedback from the measure for in clinical supervision. The supervisors

326

imply students should take a sense of responsibility (312-315), in contrast Laura

327

(extract

328

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

2), a student suggests a responsibility of the supervisor to “bring it into supervision”

329

(126-127), a possible tension between the two.

330

Interestingly the supervisor perspective differed between courses (extract 4).

331

This extract comes midway through a discussion regarding the different ways the

332

supervisors used the measure in supervision groups.

333

Extract 4: FG4 Supervisors

334

Harry: As we are talking, I’m wondering to myself now whether it’s less useful

335

in supervision. Well, not wondering. I’m certainly coming to a view that

336

it’s less useful as a supervision tool than it is as a rating evaluation tool

337

and in some ways maybe it’s a bit constraining to use it in supervision

338

because it almost feels like you’ve got to find something to say on

339

every bit and actually it doesn’t encourage the dialogue. I know we are

340

constrained by time and if we’ve got to watch the whole one hour then

341

we’ve got limited time to talk about it anyway but I wonder whether that

342

framework, maybe it’s not that conducive to giving useful feedback

343

sometimes.

344

Amy: And I think sometimes for me it’s about filling it in for filling it in’s sake, it’s

345

getting finished in the time and putting something in every box that if I

346

was free to write my own notes, or had fewer headings or a different

347

approach, I might do that differently and that might be more useful.

348

Harry: Yes, yes.

349

Amy: Yes, I don’t know.

350

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Laura: I’m wondering if there’s a bit of a both and… because I actually agree

351

with everything you’ve said and I’m wondering whether giving them

352

notes on the systemic competency scale means that they get used to

353

seeing it and get used to seeing the sections and the title and how we

354

break the session down so that when they come to then review their

355

own tapes for submission, that’s how they learn

356

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Harry begins by querying the use of the measure within supervision as

“constraining” (438) and potentially “less useful” (435-436). Amy follows this with

“filling in for filling it in sake” (445), potentially building on this idea of the measure as

constraining and restricting the process of supervision. A similar view voiced in the

previous supervisor group (Extract 3).

The extract evidences shifts in positioning through the use of pronouns. Harry

uses the first person when discussing his position on the use of the measure in

supervision e.g. “I’m wondering….” (435), “I’m certainly…” (436) and then switches

to “we” when referencing the course context “we are constrained by time” (440). This

enables his perspective to be voiced without implying this is necessarily a view

universally accepted by the group. The extract also evidences explicit focus group

talk of agreement between the supervisors (451-452).

Measuring competence

The concept of whether measuring competence of systemic principles would

be able to encapsulate the many contextual levels has been previously questioned

(Moran, 2017). The following extracts highlight this dilemma considering the

discourse of measuring competence in the wider context and the subjective nature of

the “what is noticed” (Sutherland et al., 2012).

Extract 5 comes from midway through a discussion regarding how the

measure fitted within the context of the therapy session for students.

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Extract 5: FG3 Students

530 Josie: ˚The competency scale is very pure and I don’t

think its real life˚.

531 Charlotte: It’s a bit too black and white, a bit like you can do it

or you can’t

532 do it.

In this brief extract, Josie describes the measure as “pure” not “real life” (530),

reaffirmed by Charlotte as, “too black and white” (531). The language suggests a

“purity” and linearity to the measure which contradicts the “real life” context and

layers Moran (2017) argues are an integral part of the systemic model.

The dilemma of the wider context is further evidenced within extract 6. This

extract comes from the middle of FG1 and introduces the challenge of the subjectivity

interpretation of the SPS invites. The students had been discussing how they felt the

SPS had affected their practice in the context of the university and workplace.

Extract 6: FG1 students

165 Harriet: It changes your lens doesn’t it so if you’re reviewing your

sessions

166 looking at some of the domains or all of the domains it kind of changes

167 your focus so I could for example look at a tape and think and see

168 certain stuff but then if I just had just been reading about intervening in

169 process then I could watch it again and think oh I could have

170 intervened there… so it kind of it wakes you up to things you could be

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

171 blind to or unaware of

172 Victoria: I was just … sorry

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Laura: I suppose I just feel it is a snapshot it’s just one tape in amongst all the

173

others that you’ve got so I suppose Yeah I’ve always got that in the

174

back of my mind as I said earlier it’s that you know what you score in

175

one session could be very different to what you score in another so you

176

have to take it slightly from that perspective you know we’re probably

177

not going to score very well for all 12 for every session but that doesn’t

178

mean to say that you haven’t got competence and actually I wonder if

179

there’s another way of working out with all the work that you do rather

180

than just basing it on three tapes

181

Harriet highlights how the measure “changes your lens doesn’t it” (165). The

182

intonation and rhetorical question used invites the group to consider this perspective

183

and could be viewed as a strategy to seek validation from the group. The use of the

184

term “lens” implies a way to observe a situation, within systemic practice the focus is

185

on gaining different perspectives in order to create meaning (Anderson & Swim,

186

1995). This introduces the theoretical concept of subjectivity of the “lens” that is

187

chosen to view the behaviour and the implications of this.

188

A systemic principle lies in the relational nature of action, Jones (2003)

189

discusses how “causation can only be thought of as circular, i.e. behaviour is subject

190

to constant modification in relation to feedback; that knowledge is brought forth by

191

the subjectivity of the observer” (Jones, 2003, p.349). In this context the feedback

192

provided by the SPS also modifies the subjectivity of the observer (supervisor) but

193

also of the students being observed. Harriet goes on to highlight how the measure

194

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

“wakes you up to things you could be blind to or unaware of” (170-171) again

195

reiterating the impact using the SPS can have on practice, although this is qualified

196

with “so it kind of” (170) suggesting some ambivalence to this.

197

Laura positions herself as not explicitly disagreeing with Harriet, through the

198

use of “I suppose” (173). The language used reiterates the discourse of subjectivity

199

in the scores students receive from one session to the next (175-176), describing the

200

SPS as a “snapshot” (173; Butler et al., 2018). Laura discusses how it “doesn’t mean

201

to say that you haven’t got competence” (179) reiterating the subjective nature of

202

interpretation of competence through the context of the session but also the

203

perspective or lens of the supervisor observing. Similarly, students within FG3

204

discussed the subjectivity of the measure as being “open to interpretation” (134)

205

depending on the context and perspective of the supervisor marking (Simon, 2010).

206

The challenge of measuring competence appears to be an uncontested

207

discourse amongst the student focus groups, further evidenced in Extract 7. This

208

extract follows a discussion of the challenges students faced when ensuring the 12

209

items of the SPS were met competently in sessions.

210

Extract 7: FG3 Students

211

Emma: It ju:st feels too fake in a way,

212

George: [Yeah

213

Emma: doesn’t it, just this random session you are marked on when really

214

((laughs)).

215

Katy: It’s not reflective of where you are up to, maybe,

216

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Emma: [But it’s not no:

217

Katy: or that you feel that you are up to.

218

Emma: [No. And it’s not systemic.

219

R: So it doesn’t always reflect your competence at that point.

220

George: [Absolutely.]

221

Emma: Yes. And it doesn’t necessarily show progress either, whereas if you did it

222

like (.) I don’t know, in a different way, you might [overspeaking].

223

George: [It sometimes feels a little bit…

224

Charlotte: Because if you’ve got your first tape and then your second tape

225

hopefully, your marks are going to improve

226

The extract provides further critique of the measure as “not reflective” (935) of

227

where students perceived their competence to be. Emma responds with a direct

228

response and challenges the measure as “not systemic” (940) reiterating the group

229

views in extract 5 as systemic “real life” (530) as opposed to “fake” and “pure” (531).

230

The students talk over and interrupt one another within this extract indicating an

231

increased need to share their perspective. Emma questions whether the SPS allows

232

for progression of competence to be measured (943) tentatively suggesting a “different

233

way” (944) might be helpful.

234

Extract 8 follows a discussion with a group of supervisors regarding the

235

marking of a student’s session. As the discussion progresses Stuart introduces the

236

concept of standardisation, which is a way of making something more objective

237

(Ratner, 2002), this contrasts to the systemic norm of social constructionist

238

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

theoretical stance which would hold subjectivity central (Tseliou & Borcsa, 2018;

239

extract 8).

240

241

242

Extract 8: FG 2 supervisor

243

Stuart: one of the things that’s coming up for me is this question about

244

standardisation and research is about standardisation and trying to get the

245

measure standardised and the problem is I don’t think it can be standardised

246

((laughs)) because what we’re saying is each of us has different perspectives

247

and it’s those perspectives on the students competency the difference in the

248

perspectives is what matters their difference from our difference from the

249

supervisors difference from the university’s difference

250

Stuart’s repetitive use of the word “difference” and “perspective” (203-205)

251

reiterates the challenge of measuring competence when considering the subjective

252

values of systemic theory (Burnham, 2018). The difficulty is highlighted through “the

253

problem is” (202) yet Stuart then switches to the use of “I” to make a personal claim,

254

which is potentially contentious demonstrated through subsequent laughter. Stuart’s

255

use of language “what we’re saying” (203) highlights supervisors constructing a joint

256

position in the group. The extract also evidences the many layers of subjectivity

257

through the “perspectives” of the wider context when measuring competence

258

(204206).

259

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Being systemic

260

Building on the previous two discourses, the following section discusses the

261

discourse of being systemic and the complexity of this alongside the use of the SPS.

262

Extract 9 is taken midway through a discussion regarding the purpose of the

263

measure in training.

264

265

266

Extract 9: FG 3 Students

267

Josie: because we are going in with such a broad range that it’s really difficult

268

to to (.) keep in your head because you are managing the session and

269

you are actually working with a family with 12 points to kind of guide you

270

when your also trying to think about (.) what type of questions you are

271

asking.

272

R: It’s a lot in your…

273

Josie: It’s a big big big…

274

Emma: [You are trying to like shoehorn stuff] in because you know you need to

275

submit something that will raise all those points. So if there can be some

276

sessions where you think, from knowing the family, that’s been a really

277

good session, I feel like it was systemic and I feel like the family got

278

something out of it, but that doesn’t mean it would hit all of those

279

(.)[overspeaking group] and be at the stage that (.) you know the markers

280

would think it would be a pass. So I think there’s a bit of a difference in

281

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

what you think yourself and ˚how you think your own work is progressing˚

282

and what that maybe shows in some areas.

283

George: [and I

284

Emma: It doesn’t match.

285

Charlotte: It holds back a little bit in a way, doesn’t it?

286

Lucy: Yes

287

George: But I wonder (3) like I think every single point, when you look at it

288

individually (.) I can totally see why it’s part of the criteria. I think it’s

289

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

193 really good to know these are really the skills that we are trying to build

194 you up in, so I think the the bones of it, I think is actually quite good. I

195 think what (.) we’re all saying has been marked against it and perhaps

196 using that as a marking tool is what we are finding difficult or what the

197 expectation of that marking criteria is.

This extract evidences how the students collectively construct in the group a

position to defend their ability to be systemic whilst “managing the session” (172)

alongside holding in mind all the elements of the SPS “it’s a lot” (176). An important

bit of talk in the extract highlights systemic practice being a felt quality, “I feel like it

was systemic” (181). The complexity of the discourse of being systemic, whilst

“trying to like shoehorn stuff in” (line 178) from the SPS is discussed. Emma shares

this dilemma (184-186) using “so” as a discourse marker to connect this idea of her

perceived competence and the observed competence. The students’ discomfort is

demonstrated through a mismatch between what the students view as being

systemic and what they feel the SPS measures, although this might not be an

incompatibility this is how it is potentially being perceived. Extract 10 is taken from

further on in the discussion.

Extract 10: FG3 Students

293 George: I think if there’s a deadline coming up, I’m very conscious of it and I’m very 294

much like, right, okay, have you done…? So (.) for example, was it convening 295 the

session? Then have you done the agenda ((laughs)), have you done

296 session [overspeaking], much clearer than in other sessions where I’m not

297 necessarily thinking it’s going to be one I’ll submit, I’m a bit more “go with the

298 flow”.

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

299 Charlotte: [Yeah, yeah.

300 Emma: So actually, it feels more systemic because it’s more about what

the 301 family are bringing, [yeah] it’s not me going I’ve got to get all

these points.

The students’ discuss the awareness they have of the measure (293-298)

which might distract from their systemic values and norms of being able to “go with

the flow” (298). Here George positions himself alongside a systemic identity norm

which responds to what the family brings to the session (Jones, 2003). This is

agreed by the students (299-301). They go on to reiterate how the measure

“distracts a little bit from” (308) the notion of following the lead of the family (Extract

11).

Extract 11: FG3 Students

307 Charlotte: ↑There’s a lot of pressure, isn’t there, when you’re in them

sessions

308 with families (.) I agree it distracts a little bit from…[yeah 309 Emma:

Yeah], from just going with the flow.

310 George: [Yeah].

311 Emma: Your skill’s a bit more authentic.

The group continue to support this notion of the SPS potentially restricting

their ability to be systemic, go “with the flow” (309) or be “authentic” (311). The

extract evidences further group referencing to jointly construct their position through

seeking agreement from peers (“isn’t there”, 307).

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

As the discussion within the group continues Charlotte positions the

discomfort of measuring competence as an ethical issue, “I kind of think there is a

sort of ethics type of argument around are we sending a session down a certain

route in order to meet a competency?” (962-964). Charlotte tentatively invites a new

position “I kind of think” to the group broadening the context of the implications of the

use of the SPS in potential influencing the direction of the session when trying to

hold the family in mind (Burnham, 2018).

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Discussion

The study aimed to explore whether students and supervisors viewed the

SPS as an appropriate way to assess systemic competence in training. The analysis

focused on how discourses were constructed regarding competence within focus

groups in the context of systemic training. A DA approach was used and three

dominant discourses were evidenced within the student and supervisor focus

groups: feedback as valuable, measuring competence and being systemic.

The analysis showed students and supervisors viewed the SPS as a valuable

and useful measure of systemic competence however some ambivalence was

apparent. The SPS was perceived to broaden perspectives, inviting both the

students and supervisors to view the sessions from a different perspective

(Anderson & Swim, 1995; O’Donovan, 2015). Discomfort with the broader concept

of measuring competence was evidenced particularly when students felt feedback

was not grounded within the wider systemic context (Simon, 2010). For example,

students shared the importance of receiving feedback within the context of the

supervisory relationship and similarly supervisors discussed the importance of

discussing feedback in supervision sessions. The discourse within the present study

suggested the SPS process, as currently experienced lacked this systemic concept

of a circular feedback loop that may have enabled a greater understanding of the

feedback provided from the SPS (Jones, 2003; Scaife, 2003).

Anderson and Swim (1995) refer to systemic learning in supervision as

interactional, where new knowledge and competence evolves through dialogue and

relational reflexivity. Therefore this lack of circularity may have acted as a potential

barrier in an opportunity to collaboratively develop a shared understanding of student

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

competence. Some students within this study reported viewing the process as a

‘tick-box’ exercise that was not fully utilised within the supervisory context. The

process of learning is central to systemic supervision (Burnham, 2018). Schon’s

(1987) theory of reflection on and in action are pertinent in considering the role a

measure such as the SPS could have in facilitating reflexivity within supervision. The

impact of power dynamics within a supervisory relationship however may impact the

opportunities to be circular and collaborative within supervision sessions.

Another tension that arose within the focus group talk regarded the challenge

of maintaining values of systemic practice whilst holding in mind the 12

competencies of the SPS (Burnham, 2018; Moran, 2017). Within the discourse of

being systemic students shared the difficulties of being authentic and reflexive in the

moment with clients, feeling they were unable to “go with the flow”. This was raised

as a potential ethical issue within a student discussion as to whether it was

appropriate for the students’ perception of the SPS to influence the direction of the

session when trying to hold the family in mind (Burnham, 2018). Nel (2006) had

found students were presented with dilemmas throughout their training to re-evaluate

their professional identities and roles. Although this was not an explicit focus, many

of the participants were experienced practitioners training in additional systemic

practice and therefore the discomfort could be a reflection of the re-evaluation of

their identities and competence as practitioners.

The research question focused the analysis on how the discourses regarding

competence were constructed within the context of systemic training. From a

theoretical social constructionist position the use of DA in this study enabled a

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

greater understanding of the role of language, which as discussed previously is

pertinent to systemic context (Georgaca & Avdi, 2012; Tickle & Rennoldson, 2016).

There was evidence across the five levels of DA (Appendix J, Georgaca & Avdi,

2012), with some more explicit than others (level 2, language as functional and level

3, positioning). Throughout the analyses there was evidence of joint positioning

(level 3). The groups often positioned themselves through the use of collective

pronouns or through explicitly agreeing with the discourse rarely dissenting from the

dominant discourse. In line with systemic practice this illustrates the collaborative

social constructionist perspective where a shared understanding is developed

(Anderson & Swim, 1995; Burnham, 2018). This could also be a reflection of the

roles and expectations of being within a training group as discussed in the limitations

of the study.

Tentative talk and rhetoric questions were also prevalent in the groups (level

2). This often functioned as a way to invite collaborative group talk or to raise

something that may have challenged the dominant group discourse. The concept of

subjectivity (level 5) was also alluded to within the discourse of measuring

competence and being systemic, particularly around the interpretation of the SPS

feedback. The complexities of subjectivity and competence would be interesting to

explore further in the context of systemic practice.

Researcher Reflexivity

In qualitative analyses it is important to consider reflexively the role and

influence of the researcher on the process of data collection and analysis, from a

subjective position of potential bias (Jorgensen & Phillips, 2002; Willig, 2014). The

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

epistemological position adopted for this study was social constructionism and

therefore it is important to consider the researchers role in the construction of the

group data (Georgaca & Avdi, 2012; Willig, 2014).

I was aware I too am in a “student” position as a trainee clinical psychologist

and have used competence scales throughout my clinical training, experiencing

them both positively and negatively. This therefore will have influenced how the

researcher constructed meaning and assumptions from the discourses constructed.

During clinical training, I have been taught systemic competencies and at the time of

the research I worked alongside a family psychotherapist. Therefore, I may have

focused on particular aspects of discourse that I related to and others may have

been overlooked. By attending the DA group and through supervision I had

opportunities to discuss the findings and broaden my own perspectives on the data.

Strengths and Limitations

There is limited research on the SPS and systemic competence scales more

broadly (Butler et al., 2018). The present study offered a reflective space for the

students and supervisors to discuss the SPS and the idea of competence measures

more broadly. DA allowed for a broader understanding of the SPS through the views

of the peer group context, which is less possible from other qualitative

methodologies. The advantage of a shared theoretical social constructionist

approach between DA and systemic practice (Tseliou & Borcsa, 2018) enabled a

focus on the construction and subjectivity of language and meaning used within the

focus groups.

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

As established training and supervision groups, participants might not have

felt able to disagree with the dominant group talk potentially evidenced by a lack of

dissent within the groups (Smithson, 2000). Collaboration is a consequence of the

formation of groups and the perceived need to work systemically in trainee groups

which could be a limitation of the study design (Smithson, 2018). Individual

interviews may have mitigated this.

Recruitment to the study was a challenge. Focus groups were held at two of

the five sites approached. The study was reliant on group members’ engagement

which may have been influenced by power dynamics and hierarchies within the

groups or the training context, where participants felt obliged to take part. Patterns

were discussed across the focus groups in an attempt to minimise bias. However,

the type of analysis conducted is inherently recognised to limit the generalisability

of the findings; the implications of the study are of potential relevance however to a

broader clinical audience.

Implications for Practice

The SPS is already widely used on SFP courses across the UK (Butler et al.,

2018). A primary motivator for the current study were the implications of the SPS in

clinical training for students and supervisors. Within the current healthcare climate

accountability of outcomes for the service and client are key (NHS England, 2019),

with an ethical imperative that patients receive interventions from competent

practitioners. The need for valid measures of competence is therefore crucial. The

SPS could also provide outcomes to commissioners and funders regarding the

fidelity of the training courses and student systemic competence.

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Through group talk, the discourse of feedback as valuable highlighted how

competence scales such as the SPS need to be used in practice in a meaningful

way in order for the feedback to be helpful. Both students and supervisors

recognised the need for a joined up collaborative process echoed in this study

through the discussions of the systemic feedback loop. This supports the developers’

view of the SPS to be “used in dialogue with the supervisor” (Butler et al., 2018, p 5).

Further there are implications on how training courses introduce competence

measures like the SPS highlighting the potential usefulness of them whilst

recognising the inherent limitations of these ‘moment in time’ measurements.

There are potential wider practice implications for the SPS to be used on

other clinical training courses such as the Doctorate of Clinical Psychology. As Butler

et al. (2018) allude to in their paper, there is the potential that similar to the CTS-R

(Blackburn, et al., 2017) which is used in feedback for clinical psychology trainees

CBT training, the SPS could be an alternative for systemic teaching. Additionally

there are wider implications for the development of training standards within the

association for family therapy and the guidance given regarding the use of the SPS

in systemic practice both within the current CYP-IAPT but also in on-going systemic

training (Butler et al., 2018).

Conclusion

The study contributes to a growing body of research on competence-based

measures used in clinical training (Butler et al., 2018; Tweed et al., 2010). DA of five

focus groups was conducted with students and supervisors who use the SPS within

systemic training. Discourses highlighted feedback from the SPS as valuable

particularly when grounded within a systemic context. In line with systemic values,

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

the importance was placed on the circularity of feedback within a collaborative

supervisory relationship.

The study highlighted potential clinical and practice implications of the SPS

within systemic training but also more broadly in other clinical courses. It raises

questions regarding how competence scales like the SPS can be used in a

meaningful way for students and supervisors.

STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

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Appendices

Appendix A: SPS measure (Butler et al., 2018)

Appendix B: Ethics documentation

Appendix C: Information Sheet (Student)

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Appendix D: Information Sheet (Supervisor)

Appendix E: Consent Form (Student and Supervisor)

Appendix F: Demographic questionnaire

Appendix G: Focus Group Topic guide (both supervisor and student)

Appendix H: Jefferson Transcription Conventions

Appendix I: Seven Steps in Good Quality Discourse Analysis (Potter & Wiggins,

2007)

Appendix J: Dissemination statement

Appendix K: Copy of instructions for author – Journal of Family Therapy

Appendix A

SPS measure (Butler et al., 2018)

Purpose

This scale has been devised to provide a structure for the assessment of Systemic

Family Practice (SFP) skills. It is designed to evaluate a whole session but in

addition can be used as a training and supervision tool and the focus may then be

on particular areas of competence.

Rating the scale

The seven-point scale (i.e. a 0-6 Likert scale) extends from (0) where the practitioner

does not demonstrate that skill to (6) where a high level of skill is demonstrated.

Please refer to the competence level examples found below. These examples are

intended to be used as useful guidelines only. They are not meant to be used as

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prescriptive scoring criteria, rather providing both illustrative anchor points and

guides. There is inevitable overlap of the competencies so some aspects will be

doubly rated. For example, circular questions may be rated as a change technique

and as an aspect of systemic reframing.

Adjusting the scale to the challenges presented by families

The particular therapeutic challenges of the family, and the requirement for

therapeutic intervention at a particular time, should be taken into account and

individual items scored in relation to the therapeutic needs of the family. If the marker

thinks it is appropriate that an item is not covered at all, then it should be rated at 3.

If it is covered minimally, but appropriately, it can be scored higher. For example, it

may be appropriate to hold back from exploring diversity until a later session. It

would be expected that for most sessions all dimensions would be covered.

Interrelatedness of Items

All of the Items are of course related and, as with all assessment, there is a

distinction being made that does not completely hold.

This scale has been tested for reliability and validity and is based on the

wellestablished Cognitive Therapy Scale – Revised (CTS-R) used in rating

competence in Cognitive Behavioural Therapy training and has been informed by

well-established training practice within the field of Family Therapy and Systemic

Practice. It is informed by the Competency map for Systemic Family Therapy (Roth

and Pilling 2007). It is based on the Dreyfus system, which keeps the highest levels

of attainment for very high levels of practice.

Example of the scoring layout

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Mark with an 'X' on the horizontal line, the level to which you think the practitioner

has fulfilled the core function. Please use whole and half numbers. The descriptive

features below are designed to guide your rating

N.B. When rating, take into consideration the appropriateness of therapeutic

interventions for stage of therapy, perceived family difficulty and fit with the particular

family being seen.

Competence Level Examples

0 1 2 3 4 5 6

Inappropriate absence of feature or highly inappropriate use

Very little evidence that feature has been considered and

addressed, or has been done in an inappropriate way

Evidence of some competency but examples of unhelpful

practice and general lack of consistency.

Competent, but some problems and/or inconsistencies

Competent with, minor problems and/or inconsistencies

Very competent, minimal problems and/or inconsistencies

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Excellent performance, even in the face of high levels of

complexity and challenge from family members

The benchmark for a 6 is a level of practice at the highest level expected from a

successful Systemic Family Practitioner trained to intermediate level. It is expected

that most practitioners will score a 3/4 with fewer scoring at the higher and lower

ends of the scale. An average score of 3 should be considered the minimum for

students reaching the level of clinical competence required to successfully complete

a CYP-IAPT Systemic Family Practice course (Intermediate level). It follows that in

the early stages practitioners may score at a low level as this scale is specifically for

Systemic Practice Skills and these may be unfamiliar. It is important to explain this in

order to avoid discouragement.

Please note this is a measure relating to one therapist's activity. It does not measure

the involvement of a co-therapist, a reflecting team or an in-room supervisor. There

is a free text box at the end of the scale if you wish to comment on the co-therapist,

reflecting team or supervisor.

Item 1: Interpersonal Effectiveness and Development of Therapeutic Alliance

Key features: This dimension refers to some of the key elements in the creation of a

sound therapeutic alliance - warmth, empathy, genuineness, understanding and a

non-judgmental stance. It involves verbal and non-verbal skills such as ‘joining’,

listening and creating a warm inviting atmosphere for all family members, taking

account of developmental level, age and position in the family. It includes

appropriate adherence to boundaries and use of self. A key element is the

communication of these ‘positions’ to the family members.

Practitioner's manner and interventions contribute to general

disengagement or to an atmosphere of distrust or hostility.

Difficulty in showing appropriate warmth, empathy and

understanding in relation to family members, or lack of

appropriate boundaries.

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Difficulty in demonstrating respect for the views of every family

member although there is evidence of some warmth and

empathy. Inconsistency in responding to the feedback from

family members

Good understanding of explicit meanings of communications

from all family members, resulting in a good degree of trust

developing, some evidence of inconsistencies in sustaining

relationships with all family members. Good attention to

different developmental stages of the children and young

people.

Ability to understand the implicit, as well as the explicit

meanings of the communications and demonstrates it in his/her

manner. Minor problems evident (e.g. inconsistencies or greater

struggle to connect with particular family members).

Demonstration of very good interpersonal effectiveness with all

family members. Everything is done to help family members

feel safe and confident and to engage in a sound therapeutic

alliance. Minimal problems but generally therapeutic alliance

issues are not due to ability of practitioner. Creativity in

engaging younger children and adolescents

Highly interpersonally effective, even in the face of difficulties.

Shows creativity in responses to different family members.

Qualitative feedback from supervisor related to Item 1:

Qualitative feedback from supervisor related to Item 2:

Item 2: Convening and managing the session

Key features: This includes five main elements and practitioners are expected -

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1. To begin the session in a way that is inclusive of all family members, ensuring the

involvement of all present including small children. This includes appropriate use of toys

and drawing materials.

2. To collaboratively agree a clear focus and to hold onto that focus through the session

allowing for useful diversions when necessary.

3. To manage the session so that it has a beginning, middle and end, within the time

constraints set, and managing essential administrative tasks sensitively within the

allotted time.

4. Ensure that discussions are appropriate for the stage of the work, client needs and point

in the session. Where appropriate making good connections with past sessions and

future sessions.

5. Pacing the session to fit the needs of family members.

Poor beginning to the session and no attempt at engaging or

agenda setting. Session pace does not fit the needs of family

members.

Little time given to convening, poor time management and lack of

focus, or the application of an over rigid agenda. Problems with

pacing.

Time given to convening but may not include all family members.

Lack of collaboration in agenda setting but some attempts to create

focus in the session. Some problems with time management.

Good beginning to session and appropriate agenda but may be a

lack of consistency in focus and pacing of session. May include

some problems with time management, the inclusion of all family

members, or ending the session.

Good convening, appropriate agenda, minor difficulties in focus and

time management. Good pacing of the session.

Good convening and appropriate agenda set with good

collaboration and focus throughout the session. All administrative

tasks covered and good sense of beginning, middle and end to the

session. Focus and flexibility are used appropriately.

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Excellent collaborative agenda set, and reviewed despite

challenges in the therapeutic relationship. Ability to hold to the

shared goals whilst also addressing other issues that may arise and

appropriately need to be addressed. All administrative tasks

covered with sufficient time allowed for discussion. Session brought

to an appropriate ending.

Item 3: Collaboration

Key features: Working collaboratively is central to a systemic approach. The aim is

for all family members to be active in the session and involved in decisions about

goals and the development of the work. There must be clear evidence of productive

teamwork, with the practitioner skilfully encouraging all family members to participate

fully (e.g. through questioning techniques, shared problem solving and decision

making). The expertise and knowledge of family members should be identified,

acknowledged and used, and the practitioner should aim to use their own expertise

without inflexibly maintaining an expert position. This will include sharing of

information and inviting different kinds of feedback. Another element is the ability to

use tentative language that invites a co-construction of ideas.

Family members are actively prevented or discouraged from being

collaborative.

The practitioner is too controlling, dominating, or passive and does

not actively invite different forms of collaboration.

There are occasional attempts at collaboration, but with little

consistency and some family members may be excluded from this

process.

Teamwork evident, but some problems with collaboration (e.g. not

enough time allowed for the family member to reflect and participate

actively). Some use of tentative language as a tool to invite

discussion.

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Effective collaboration is evident, but not entirely consistent. The

practitioner checks out the family members’ experience of the

session and is able to adapt the session in response to feedback.

Consistent use of tentative language.

Effective collaboration evident throughout most of the session, both in

terms of verbal content and sharing of information. Good attention

paid to style and culture of family and the impact of this on the

collaborative process. Flexibility in ways of encouraging collaboration

and regular use of ‘checking out’ with the family. ( relational

reflexivity)

Effective collaboration throughout the session (all family members),

and creativity and skill in responding to any challenges to this

process.

Qualitative feedback from supervisor related to Item 3:

Item 4: Conveying a systemic view of family life, wider context and relationship

of family to the problem

Key features: A key element in SFP is to help family members understand difficulties

relationally and in the context of family and other relationships. This includes ideas

such as circularity, family beliefs, behaviour and relationship patterns, narratives and

wider system involvement. This systemic reframing is an essential basis for SFP

interventions. This is often achieved through good use of circular and other

questions together with reframing techniques and the process of the inclusion of

multiple family members.

Practitioner conveys no evidence of systemic understanding during

the session.

Some attempts to introduce systemic understanding but clumsy,

and with no attempt to take into account the beliefs of family

members.

The conveying of an over rigid and narrow systemic explanation

which may blame the family, Little attempt to take into account

beliefs of family members. Limited attention to wider systems.

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Ability to apply systemic reframes and descriptions but with limited

time taken to obtain feedback from family members or explore

different ideas. Ability to use questions and track a circular

sequence of interaction but may be inconsistencies.

Good ability to reframe systemically in a way that takes into

account history over time, developmental issues and effect of

problem on the family. Good use of questions to elicit systemic

connections.

Consistent use of systemic ideas throughout the session adapted

for all family members with good time given for discussion and

feedback. Excellent use of questions to elicit systemic connections.

Creativity in conveying systemic ideas including the use of

nonverbal techniques and questions. Ability to manage challenges

to a systemic perspective in a way that maintains a good

therapeutic alliance.

Qualitative feedback from supervisor related to Item 4:

Item 5: Conceptual Integration

Key features: A flexible conceptual map or formulation is necessary to structure the

work and create coherence. This dimension refers both to the practitioner’s own

conceptualisation, which should manifest itself in a coherent approach within the

session, and the ability to convey these ideas to family members. It is expected that

these maps will increase in complexity as the practitioner gains experience of

different models and approaches.

No evidence of conceptual map or formulation.

Occasional evidence of conceptual thinking but no coherence or

consistency in the session.

Some evidence of conceptual thinking but not carried through, or

linked well enough to formulation.

Use of conceptual thinking evident in the session and informs

most interventions. Some communication of ideas with family

members. However, there may be inconsistencies or lapses.

Good conceptual thinking clearly informing interventions but

limited to a narrow range of ideas with some lack of skill in

involving all family members in the thinking.

Complex conceptualisations informing the session and good skills

in taking account of the thinking and positions of family members

when introducing the ideas. Clear connections between

interventions, formulation and systemic theories.

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Good conceptualisations, open to revision and review and

communicated in a collaborative way to family members.

Coherent session and may include sharing of research findings or

using a range of verbal and non-verbal ways of communicating

ideas.

Qualitative feedback from supervisor related to Item 5:

Item 6: Use of questioning

Key features: The use of questioning is a key element in systemic work and in most

interventions. It requires a stance of openness and curiosity as well as an ability to

use questions in a strategic way to enhance observation and change thinking.

Hypothesising is important as a guide to questioning and it also involves the ability to

hold a position of uncertainty.

Very little evidence of purposeful questioning.

Some questions but tend to be closed or focused on gathering

specific information and have an interrogatory quality.

Use of some circular and other types of questions but with no

evidence of a guiding hypothesis. No clear use of family

feedback to guide direction of questioning.

Use of purposeful questions organised around an idea or

hypothesis identified in the on-going formulation and evidence of

working from feedback.

Good circular and other questions used for interventions as well

as information gathering. Good attention to feedback and style of

questioning differentiated well to fit with needs of different family

members and purpose.

Excellent range of questioning organised to support a range of

interventions and designed well to fit with different family

members. Evidence that they are making a difference to family

thinking and functioning.

Good use of questioning carefully following feedback and

contributing continuously to the therapeutic plan, maintained

even when there are difficulties and fully involving all family

members.

Qualitative feedback from supervisor related to Item 6:

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Item 7: Feedback

Key features: Feedback is used in a number of ways and includes reframing. It is

the ability to provide a response to session content and process, that is helpful to

family members. It is used to enhance interventions such as externalisation (unique

outcomes) and solution focused approaches (exceptions) and to highlight and

encourage more positive behaviour and relationships (scaffolding). It includes

positive feedback and positive connotation. This is different from the feeding back to

a family what has been said to the therapist. This latter intervention is a key part of

demonstrating listening skills and empathy, especially evident in the initial stages of

the work and is rated under interpersonal skills. It is also different from the important

skill of working in response to feedback from the family. This is covered in a number

of items including questioning interventions.

Absence of feedback.

Feedback only given if requested and is not purposeful. The

effect on family members is not sufficiently considered.

Some feedback but mostly when summing up or giving more

formal feedback such as at the end of the session.

Some evidence of taking opportunities to feed back and

support positive aspects but not consistent and not always

taking account of the way in which feedback may be

experienced.

Good use of feedback when associated with a particular

intervention (e.g. supporting changes in behaviour or

relationships) but less evident throughout the session. Good

account taken of effect on all family members in the session.

Good use of feedback to support a variety of interventions

throughout the session and which may include practitioner’s

own reactions and experiences. Good pacing.

Excellent use of feedback to all family members even in the

face of difficulties. Good flexibility in adapting to family style.

Qualitative feedback from supervisor related to Item 7:

Item 8: Intervening in process during the session

Key features: This requires an understanding of the process between family

members (patterns of interaction), and also the ability to intervene directly in that

process through active questioning, communication work, enactment, role play,

coaching. It includes active interventions to help family members experience different

positions in the family and therefore encouraging empathy. It requires a leadership

approach that engages and involves family members in the process. It needs to be

based on a systemic understanding and a good therapeutic alliance.

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

No evident awareness of process as a focus for intervention or

comment.

Some awareness of process but no connections made between

content and process, or attempt to address process in the session.

Some awareness of process but interventions are not followed

through or connected well enough to the session in general.

Evidence awareness of process and attempts in the session to help

family make changes. Simple interventions, such as slowing the

process and taking turns in communicating, and helping parental

alliance will be achieved.

Good use of process observations and skills in discussions and

direct interventions. Good attention paid to level of engagement and

“fit” for all family members.

A range of ways of intervening in process including enactment, work

to strengthen parent subsystem and different ways of working with

communications. Will stay focused on the intervention.

Creativity in working with process adapted to suit different family

members even when particular challenges to carrying out the

interventions. Maintenance of good therapeutic relationship with all

family members and appropriate use of humour and self disclosure.

Qualitative feedback from supervisor related to Item 8:

Item 9: Working with power and difference

Key features: This includes four main elements.

1. Working to reveal differences between family members and appropriately working

with that difference.

2. Ability to hold and respect different positions and perspectives within the family.

3. Using an understanding of power differentials between family members, practitioner

and the family, and within different wider contexts to inform interventions

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

4. Paying attention to differences such as ability, gender, race, sexuality, spiritual

beliefs, age, etc. and the way in which these inform behaviour, relationships and

beliefs; exploring and taking account of these in the work.

5. Taking an ethical stance to ensure protection of vulnerable family members. This

includes attention to safeguarding.

No attention to difference.

Some awareness of difference but not explored.

Some areas of difference noted but no effort made to appropriately

explore these. No exploration of cultural and power differences in the

wider community.

Some attention to difference and exploration of the meaning of this for

family members. Ability to raise concerns of safety and ask about power

and difference issues such as class, economic status, culture, religion and

ethnicity.

Good exploration of difference and its meanings, and attention to more

subtle power differentials within the family, therapy and wider contexts,

including all family members. Appropriate exploration of any safeguarding

issues in a way that optimises the possibility of collaboration and protects

vulnerable members of the family.

Taking account of difference throughout the session and making it an

ongoing part of the understanding of the family. Use of curiosity to explore

difference. Use of questioning to explore difference and power issues

between therapy (team, agency) and the family. (relational reflexivity)

Excellent attention to difference and good skills in talking about it even in

difficult circumstances. Using creative ways to help family members

explore their differences further in a positive and productive way.

Qualitative feedback from supervisor related to Item 9:

Item 10: Exploring and managing emotions in sessions

Key features: Working with the connections between behaviour, relationships,

beliefs and emotions is a key skill. Practitioners need to be able to talk about

emotions but contain them safely in a family session. They also have to ensure that

family members feel understood and can develop strategies to manage their own

emotions

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

No eliciting of emotions or ability to respond appropriately to emotional

content of session.

Occasional eliciting of emotion but limited to certain family members

or responded to in an unhelpful way.

Some questioning about emotions and appropriate reaction and some

notice of emotional response in session but inconsistent or limited to

particular emotions or family members.

Ability to talk about emotions that arise in session discussions,

connect them to relationships and behaviour. Ability to tolerate and

contain emotions in a helpful way . The discussions are superficial or

not carried through.

Ability to rigorously explore emotions, even those which are more

difficult for both practitioner and family members. Attends to responses

of all family members in the room. Begins to work with strategies to

manage emotions.

Acknowledges and discusses a range of emotions including

happiness, conflict, anger and sadness. Observes the atmosphere in

the room and subtle signs of emotional atmosphere. Helps all family

members understand and explore emotional aspects of relationship

taking account of history and context.

Works positively with a range of emotions in a number of different

ways even when the emotional atmosphere in the session is

challenging and some family members may want to stifle the

discussion. Maintaining a good therapeutic relationship.

Qualitative feedback from supervisor related to Item 10:

Item 11: Use of Change techniques

Key features: Practitioner skilfully uses appropriate interventions in line with the

formulation. There is some overlap with a number of other items, and activities may

be rated more than once. This item focuses on the ability of the practitioner to use a

range of interventions to help initiate and support change.

Three features need to be considered:

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

1. Appropriateness of interventions in relation to the formulation and evidence

base.

2. Skill in the application of the methods.

3. The way the intervention fits for the family members – paying attention to

pace, developmental level, language, therapeutic alliance and acceptability of

intervention.

Practitioner fails to use, appropriate interventions, or uses

interventions that are not appropriate or connected to the needs of

the family.

Practitioner initiates interventions but they are poorly executed and/or

lack sensitivity to needs of the family at that particular time.

Practitioner uses some appropriate interventions but not followed

through or not well enough connected to needs of family.

Practitioner applies a number of methods in competent ways,

although some problems may be evident (e.g. the interventions are

incomplete or poorly presented to the family).

Practitioner applies a range of methods with skill and flexibility,

enabling family members to develop new perspectives and make

changes Minor problems evident.

Practitioner systematically applies an appropriate range of methods

in a creative, resourceful and effective manner. Minimal problems.

Excellent range of interventions, skilfully carried out even in the face

of difficulties.

Qualitative feedback from supervisor related to Item 11:

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Item 12: Incorporating the outside world

Key features: It is important for practitioners to bring wider systems and networks

into their formulation and into interventions. This could include other family members,

professional networks or important groups such as community, church, peer group

and school. It also involves the identification of pressures and stresses such as

poverty, unemployment or discrimination, which are important in understanding

difficulties and planning ways of helping.

No inclusion of anyone outside immediate family members in

session discussions.

Occasional questions asked about external networks, context and

wider family but no follow up or continued reference to these in the

session.

Some questioning about external world but little empathy with the

experience of family members and little response to issues raised

by family members.

Good exploration of wider contexts and some attempts to explore

the experience of different family members and to incorporate this

into conceptualisation of the difficulties. Identification of important

people

who may be included in session or part of liaison work.

Wider contexts clearly part of thinking throughout the session and

good ability to follow up information brought in by family members.

Ability to work collaboratively to bring together views of

professionals and other networks and to take wider context into

account when devising tasks.

Ability to use relationships with wider contexts as a core part of the

work. To give tasks that make use of external resources and help

family members to identify and work with some of the constraints

and opportunities available in the outside world.

Ability to explore different levels of relationship with outside world

and continuously monitor, and discuss how these affect family

members even when this is difficult and to do so in a way that fits

for family and family members.

Qualitative feedback from supervisor related to Item 12:

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

Where appropriate, please comment on practitioner’s ability to effectively make use of

supervisory comments and interventions from reflecting team and /or co-therapist

Systemic Family Practice/Systemic Skills Rating Scale

Please see guidance notes

Mark with an 'X' on the horizontal line, using whole and half numbers, the level to

which you think the practitioner has fulfilled the core function.

N.B. When rating, take into consideration the appropriateness of therapeutic

interventions for stage of therapy, perceived family difficulty and fit with the particular

family being seen.

1. Interpersonal Effectiveness and Development of Therapeutic Alliance

0 1 2 3 4 5 6

2: Convening and managing the session

0 1 2 3 4 5 6

3. Collaboration

0 1 2 3 4 5 6

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

4. Conveying a Systemic View

0 1 2 3 4 5 6

5. Conceptual Integration

0 1 2 3 4 5 6

6. Use of Questioning

0 1 2 3 4 5 6

7. Feedback

0 1 2 3 4 5 6

8. Intervening in Process

0 1 2 3 4 5 6

9. Working with Power and difference

0 1 2 3 4 5 6

10. Exploring and managing emotions in sessions

0 1 2 3 4 5 6

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STUDENT AND SUPERVISOR EXPERIENCES OF THE SPS

11. Use of change techniques

0 1 2 3 4 5 6

12. Incorporating the outside World

0 1 2 3 4 5 6

Final Comments (areas of strength/development)

Demographic questionnaire

SCHOOL OF PSYCHOLOGY

Demographic Questionnaire

Is the systemic family practice- systemic competency scale (SFP-SCS) a helpful

measure for students in the development and understanding of their systemic

competency?

Version 1 27.10.2017

Thank you for agreeing to complete the following questionnaire. All information collected on

the questionnaire will remain anonymous. The questionnaire will ask you to provide some

information about yourself. You do not have to provide an answer to the question and data

can be withdrawn at any point.

Gender:

Age:

Ethnicity:

Job title:

Length in current position:

Are you currently studying? Yes No N/A (Please circle)

What year of study are you in?

Previous qualifications (please specify):

Focus group topic guide

(Bracketed italics represent amendments for supervisor group)

Introduction – introduce the study, the purpose, procedure. Discuss confidentiality.

Offer opportunities to discuss the research project and any issues that may arise (i.e.

withdrawal from the study, confidentiality). Ensure participants have read and

understood the information sheet and the consent form is signed by the participant

prior to starting the group.

Once people have settled in the group, check with the group whether they know

each other, if not start the group with introductions and getting to know one another.

Initial question: “It would be really useful to start by hearing your experiences of

receiving feedback from the SPS measure / (using the SPS)” Topics to facilitate

group discussion that link to the RQs:

• Learning: Can someone talk about how the measure has impacted their learning?

Were you surprised? Does it fit with what you think about your skills?

• Receiving / (giving) feedback: How did you find the process of feedback? Is (was)

it helpful? What could be improved?

• Identity: How does this feedback reflect your identity as practitioners? Does it reflect

your competence? (How does the feedback help students reflect on their identity?)

• Impact on clinical practice: Can you see evidence of change in your practice using

the measure? What change? Why? (reflections on clinical use?)

Conclusion- Summarise the discussions, thank participants for their time, debrief,

and discuss dissemination of results

Jefferson Transcription Conventions

Adapted from Jefferson, 2004

(0.5)

Number in brackets indicates a time gap in tenths of a second.

(.)

A dot enclosed in brackets indicates a pause in the talk of less than two-

tenths of a second.

‘Equals’ sign indicates ‘latching’ between utterances.

[ ]

Square brackets between adjacent lines of concurrent speech indicate

the onset and end of a spate of overlapping talk.

(( ))

A description enclosed in a double bracket indicates a non-verbal

activity.

A dash indicates the sharp cut-off of the prior sound or word.

Colons indicate that the speaker has stretched the preceding sound or

letter.

(inaudible) Indicates speech that is difficult to make out. Details may also be

given with regards to the nature of this speech (eg. shouting).

. A full stop indicates a stopping fall in tone. It does not necessarily

indicate the end of a sentence.

↑↓ Pointed arrows indicate a marked falling or rising intonational shift.

They are placed immediately before the onset of the shift.

Under Underlined fragments indicate speaker emphasis.

CAPITALS Words in capitals mark a section of speech noticeably louder than that

surrounding it.

° ° Degree signs are used to indicate that the talk they encompass is

spoken noticeably quieter than the surrounding talk.

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